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Case study questions for Chalfont Centre

Thank you for sharing your story with us. You could help us to secure more funds for life-changing research and help raise awareness of epilepsy through the media.

IMPORTANT: On receipt of your completed form, we will keep your details on file and will be in touch if we are able to use your story. Please be assured that we would never pass on your details to the media without contacting you first. Any questions of concerns please feel free to contact the press office on 01494 601417.

Personal details

Male-female

Male

female

Other

Title

First name (required)

Second name (required)

Address line 1

Address line 2

Address line 3

City

County

Postcode

Date of birth

Telephone number (home)

Telephone number (mobile)

Telephone number (work)

Email address

Occupation

Do you have epilepsy?

Yes

Are you the family member/carer/supporter of someone with epilepsy?

Yes

Are you/the person you care for still having seizures?

Yes

What type of seizures do you/the person you care for have?

How does epilepsy affect you/the person you care for and those around you/them?

Are you/the person you care for taking anti-seizure medication?

Yes

Have you/the person you care for ever had any side effects directly related to your anti-seizure medication?

Now

In the past

Please tell us more about your side effects

Have you/the person you care for had surgery for your/their epilepsy?

Yes

When and why were you/the person referred to Gowers/the Chalfont Centre and what treatment have you/they received here?

Were you/they an inpatient/outpatient/both?

Inpatient

Outpatient

Both

Please tell us more about your/their experience as an inpatient/outpatient/both. How long were you/they treated? When did you/they switch from inpatient to outpatient, etc?

Did you/they receive a different diagnosis from your original one when you were referred here?

Yes

If yes, please provide more details. Did you/they have to change your medication? Were there any other changes?

Did you/they have an EEG/MRI/TMS-EEG scan here?

EEG

MRI

TMS-EEG

No, none of these

Tell us more about the procedure, how did it make you feel, how long did it take, what was the outcome of this/these tests?

Have you/they had a VNS fitted?

Yes

If yes, how has the VNS worked for you? Any side effects?

Have you/they had your/their genome sequenced here?

Yes

If yes, please write more details here

How often do you/they visit the centre and see your/their neurologist?

Has treatment at the Chalfont Centre made a difference to your/their life, for example through better seizure control, frequency/severity of seizures, better tolerated medication? Please tell us about your/their experience and any changes you have experienced in your/their life?

What would make the biggest difference to you/the person you care for with your epilepsy?

Please confirm that you are happy to share your story through the media and for your story to be used in fundraising applications and on our website and social media.

Yes

Please confirm that you are happy to use your real name.

Yes

Please tick here if you would like to receive further details of our work

Yes

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