Things that Get in the Way of Taking Anti-seizure Medicine (Caregivers)

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

We realize that taking medicine for seizures can be hard at times. Some patients and families have shared that the following things get in the way of taking anti-seizure medicine. We want to hear from you and learn what, if anything, gets in the way of your child/family member taking his/her medication as prescribed.

First and Last Name (optional)

Today's date *

YYYY

City, State where patient resides. *

Please list the name of the person who asked you to fill out this form. *

Let us know which of these things, if any, apply to your child/family member related to taking their anti-seizure medicine. (Please check all that apply): *

Trouble remembering (e.g., forget).

The medicine tastes bad.

The pills are too hard to swallow.

Side effects (like sleepiness or dizziness).

Not wanting other people to know he/she takes medicine.

We do not think he/she needs the medicine.

He/She takes too many medicines or it is too many times a day.

The medicine does not always control/stop his/her seizures.

Run out of medicine.

The medicine instructions are confusing.

It is inconvenient (for example, he/she has to cut the pills in half for dosing).

Taking the medicine gets in the way of other activities (like sports or work).

Cannot afford the medicine.

Sometimes we choose not to take them.

Difficulty getting to the pharmacy to pick up medicine.

Insurance problems.

Worry medicine may impact his/her ability to have children in the future.

Other:

Required

How do you and your child/family member communicate with his/her provider? *

Phone

Fax

Patient Portal

None

Your feedback will help your epilepsy team provide you with the best available supports and resources. Thank you for taking the time to fill out this form.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms