{"id":1356,"date":"2018-05-02T19:49:56","date_gmt":"2018-05-02T18:49:56","guid":{"rendered":"https:\/\/www.orchardmedprac.scot.nhs.uk\/?page_id=1356"},"modified":"2020-10-05T21:40:09","modified_gmt":"2020-10-05T20:40:09","slug":"epilepsy-review-form","status":"publish","type":"page","link":"https:\/\/www.orchardmedprac.scot.nhs.uk\/your-record\/electronic-reviews\/epilepsy-review-form\/","title":{"rendered":"Epilepsy Review Form"},"content":{"rendered":"<link rel='stylesheet' id='formidable-css' href='https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-content\/plugins\/formidable\/css\/formidableforms.css?ver=4271634' media='all' \/>\n<div class=\"frm_forms  with_frm_style frm_style_big_text\" id=\"frm_form_18_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_js_validate  frm_pro_form \" id=\"form_hnlsj634\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Epilepsy Review<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"18\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_18\" id=\"frm_hide_fields_18\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"hnlsj634\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_18\" name=\"frm_submit_entry_18\" value=\"f1f4a5cd04\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/1356\" \/><div id=\"frm_field_417_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_xu1tj634\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xu1tj634\" name=\"item_meta[417]\" value=\"\"  data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_418_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_xt7az634\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xt7az634\" name=\"item_meta[418]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_419_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ppbxb634\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ppbxb634\" name=\"item_meta[419]\" value=\"\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_ppbxb634\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_ppbxb634\">Enter Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_420_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_w1eya634\" class=\"frm_primary_label\">Date of birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_w1eya634\" name=\"item_meta[420]\" value=\"\"  data-frmmask=\"99\/99\/9999\" style=\"width:200px\" placeholder=\"DD\/MM\/YYYY\" data-reqmsg=\"Date of birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" class=\"auto_width\" aria-invalid=\"false\" pattern=\"\\d\\d\\\/\\d\\d\\\/\\d\\d\\d\\d$\"   aria-describedby=\"frm_desc_field_w1eya634\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_w1eya634\">Please use format day\/month\/year e.g. 12\/05\/1979<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_421_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_spq8l434\" class=\"frm_primary_label\">Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_spq8l434\" name=\"item_meta[421]\" value=\"\"  data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_422_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Your Epilepsy Review<\/h3>\r\n\r\n\r\n<div id=\"frm_field_423_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n    <label for=\"field_qrd2q\" class=\"frm_primary_label\">How long has it been since your last epileptic fit?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_423-422-0\"><label for=\"field_qrd2q-0\">\t\t<input type=\"radio\" name=\"item_meta[423]\" id=\"field_qrd2q-0\" value=\"Less than a week\"\n\t\t   data-sectionid=\"422\" data-reqmsg=\"How long has it been since your last epileptic fit? cannot be blank.\" data-invmsg=\"How long has it been since your last epileptic fit? is invalid\" aria-invalid=\"false\"  \/> Less than a week<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_423-422-1\"><label for=\"field_qrd2q-1\">\t\t<input type=\"radio\" name=\"item_meta[423]\" id=\"field_qrd2q-1\" value=\"1 to 4 weeks\"\n\t\t   data-sectionid=\"422\" data-reqmsg=\"How long has it been since your last epileptic fit? cannot be blank.\" data-invmsg=\"How long has it been since your last epileptic fit? is invalid\" aria-invalid=\"false\"  \/> 1 to 4 weeks<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_423-422-2\"><label for=\"field_qrd2q-2\">\t\t<input type=\"radio\" name=\"item_meta[423]\" id=\"field_qrd2q-2\" value=\"1 to 6 months\"\n\t\t   data-sectionid=\"422\" data-reqmsg=\"How long has it been since your last epileptic fit? cannot be blank.\" data-invmsg=\"How long has it been since your last epileptic fit? is invalid\" aria-invalid=\"false\"  \/> 1 to 6 months<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_423-422-3\"><label for=\"field_qrd2q-3\">\t\t<input type=\"radio\" name=\"item_meta[423]\" id=\"field_qrd2q-3\" value=\"6 to 12 months\"\n\t\t   data-sectionid=\"422\" data-reqmsg=\"How long has it been since your last epileptic fit? cannot be blank.\" data-invmsg=\"How long has it been since your last epileptic fit? is invalid\" aria-invalid=\"false\"  \/> 6 to 12 months<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_423-422-4\"><label for=\"field_qrd2q-4\">\t\t<input type=\"radio\" name=\"item_meta[423]\" id=\"field_qrd2q-4\" value=\"Over 12 months\"\n\t\t   data-sectionid=\"422\" data-reqmsg=\"How long has it been since your last epileptic fit? cannot be blank.\" data-invmsg=\"How long has it been since your last epileptic fit? is invalid\" aria-invalid=\"false\"  \/> Over 12 months<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_424_container\" class=\"frm_form_field form-field  frm_top_container horizontal_radio\">\r\n    <label for=\"field_xtq67\" class=\"frm_primary_label\">Are you currently on treatment for epilepsy?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_424-422-0\"><label for=\"field_xtq67-0\">\t\t<input type=\"radio\" name=\"item_meta[424]\" id=\"field_xtq67-0\" value=\"Yes\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"Are you currently on treatment for epilepsy? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_424-422-1\"><label for=\"field_xtq67-1\">\t\t<input type=\"radio\" name=\"item_meta[424]\" id=\"field_xtq67-1\" value=\"No\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"Are you currently on treatment for epilepsy? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_425_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <label for=\"field_wn3tm\" class=\"frm_primary_label\">On average how often do you have an epileptic fit?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_425-422-0\"><label for=\"field_wn3tm-0\">\t\t<input type=\"radio\" name=\"item_meta[425]\" id=\"field_wn3tm-0\" value=\"None\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"On average how often do you have an epileptic fit? is invalid\" aria-invalid=\"false\"  \/> None<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_425-422-1\"><label for=\"field_wn3tm-1\">\t\t<input type=\"radio\" name=\"item_meta[425]\" id=\"field_wn3tm-1\" value=\"Many seizures a day\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"On average how often do you have an epileptic fit? is invalid\" aria-invalid=\"false\"  \/> Many seizures a day<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_425-422-2\"><label for=\"field_wn3tm-2\">\t\t<input type=\"radio\" name=\"item_meta[425]\" id=\"field_wn3tm-2\" value=\"Daily seizures\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"On average how often do you have an epileptic fit? is invalid\" aria-invalid=\"false\"  \/> Daily seizures<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_425-422-3\"><label for=\"field_wn3tm-3\">\t\t<input type=\"radio\" name=\"item_meta[425]\" id=\"field_wn3tm-3\" value=\"1 to 6 seizures a week\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"On average how often do you have an epileptic fit? is invalid\" aria-invalid=\"false\"  \/> 1 to 6 seizures a week<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_425-422-4\"><label for=\"field_wn3tm-4\">\t\t<input type=\"radio\" name=\"item_meta[425]\" id=\"field_wn3tm-4\" value=\"2 to 4 seizures a month\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"On average how often do you have an epileptic fit? is invalid\" aria-invalid=\"false\"  \/> 2 to 4 seizures a month<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_425-422-5\"><label for=\"field_wn3tm-5\">\t\t<input type=\"radio\" name=\"item_meta[425]\" id=\"field_wn3tm-5\" value=\"1 to 12 seizures a year\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"On average how often do you have an epileptic fit? is invalid\" aria-invalid=\"false\"  \/> 1 to 12 seizures a year<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_426_container\" class=\"frm_form_field form-field  frm_top_container horizontal_radio\">\r\n    <label for=\"field_5rorz\" class=\"frm_primary_label\">Are you a woman aged between 18 and 55?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_426-422-0\"><label for=\"field_5rorz-0\">\t\t<input type=\"radio\" name=\"item_meta[426]\" id=\"field_5rorz-0\" value=\"Yes\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"Are you a woman aged between 18 and 55? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_426-422-1\"><label for=\"field_5rorz-1\">\t\t<input type=\"radio\" name=\"item_meta[426]\" id=\"field_5rorz-1\" value=\"No\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"Are you a woman aged between 18 and 55? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_427_container\" class=\"frm_form_field form-field  frm_top_container horizontal_radio\">\r\n    <label for=\"field_62tze\" class=\"frm_primary_label\">Would you like information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_427-422-0\"><label for=\"field_62tze-0\">\t\t<input type=\"radio\" name=\"item_meta[427]\" id=\"field_62tze-0\" value=\"Yes\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"Would you like information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_427-422-1\"><label for=\"field_62tze-1\">\t\t<input type=\"radio\" name=\"item_meta[427]\" id=\"field_62tze-1\" value=\"No\"\n\t\t   data-sectionid=\"422\" data-invmsg=\"Would you like information regarding contraception, conception and pregnancy and how this is affected by your epilepsy medication? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_428_container\" class=\"frm_form_field  frm_html_container form-field\">\n<div class=\"well\">Our practice nurses are happy to discuss this with you. Please contact the practice to arrange an appointment with a practice nurse.<\/div>\n<\/div>\n<div id=\"frm_field_1195_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_w0lgw\" id=\"field_w0lgw_label\" class=\"frm_primary_label\">Any comments you would like to add?\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[1195]\" id=\"field_w0lgw\" rows=\"5\"  data-sectionid=\"422\" data-invmsg=\"Any comments you would like to add? is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_430_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Privacy Policy<\/h3>\r\n\r\n\r\n<div id=\"frm_field_431_container\" class=\"frm_form_field  frm_html_container form-field\">This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our <a href=\"https:\/\/www.orchardmedprac.scot.nhs.uk\/about-us\/practice-policies\/patient-record\/how-we-use-your-data\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a> to discover how we protect and manage your submitted data.<\/div>\n<div id=\"frm_field_432_container\" class=\"frm_form_field form-field  frm_required_field frm_inline_container vertical_radio\">\r\n    <label for=\"field_jkc39\" class=\"frm_primary_label\"> \r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_432-430-0\"><label for=\"field_jkc39-0\"><input type=\"checkbox\" name=\"item_meta[432][]\" id=\"field_jkc39-0\" value=\"I consent to the practice collecting and storing my data from this form.\"  data-sectionid=\"430\" data-reqmsg=\"We need your consent to proceed. Please tick the box to consent.\" data-invmsg=\"  is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I consent to the practice collecting and storing my data from this form.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<input name=\"frm_state\" type=\"hidden\" value=\"EMiuZvbUwThqI8cBn7LJn9eka6QdRmUE1Z2ChN\/gtl8=\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Send<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":6577921,"featured_media":0,"parent":1340,"menu_order":9,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_uag_custom_page_level_css":"","footnotes":"","_links_to":"","_links_to_target":""},"acf":[],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false,"mailpoet_newsletter_max":false},"uagb_author_info":{"display_name":"Editor","author_link":"https:\/\/www.orchardmedprac.scot.nhs.uk\/author\/gary-genpra\/"},"uagb_comment_info":0,"uagb_excerpt":null,"_links":{"self":[{"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1356"}],"collection":[{"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/users\/6577921"}],"replies":[{"embeddable":true,"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/comments?post=1356"}],"version-history":[{"count":1,"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1356\/revisions"}],"predecessor-version":[{"id":13918,"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1356\/revisions\/13918"}],"up":[{"embeddable":true,"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/pages\/1340"}],"wp:attachment":[{"href":"https:\/\/www.orchardmedprac.scot.nhs.uk\/wp-json\/wp\/v2\/media?parent=1356"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}