Treatment Satisfaction Questionnaire
The Treatment Satisfaction Questionnaire can help your doctor develop a treatment plan that's right for you. It asks you questions about problems people with epilepsy may potentially experience. Some of these may be symptoms of epilepsy itself, others may be related to the medication you take for your seizures, and still others may be unrelated.
Please print this page and take the time to answer the questions below. Bring your completed questionnaire when you meet with your doctor.
| Name:________________________________________ |
Date:_______________ |
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| 1. |
Do you feel that your seizures are adequately controlled? |
Yes No |
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Explain:
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| 2. |
Are you having difficulty thinking clearly (for example, problems concentrating, communicating, or remembering things)? |
Yes No |
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Explain:
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| 3. |
Are you bothered by changes in your physical appearance (for example, changes in weight, hair loss or unusual hair growth, acne or rash, gum problems)? |
Yes No |
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Explain:
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| 4. |
Are your feelings or moods out of the ordinary (for example, sadness, anger, nervousness, too much or too little energy)? |
Yes No |
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Explain:
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| 5. |
Do you find that you have problems with coordination (for example, you feel dizzy or unsteady)? |
Yes No |
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Explain:
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| 6. |
Do any of the above symptoms you described or other problems you may be experiencing interfere with your daily activities or life goals (for example, it has affected your job performance, schoolwork, or your relationships with family or friends)? |
Yes No |
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Explain:
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