Tell us your Epilepsy story
Have you been diagnosed with Epilepsy? (Optional)
Select One
Yes
No
Not Sure
Not Applicable
Does Epilepsy impact relationships with family or caregivers? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Does Epilepsy impact your daily exercise or other activities? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Does Epilepsy impact your mental health? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Does Epilepsy impact your healthcare costs? (Optional)
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Yes
Somewhat
No
Not Sure
Not Applicable
Are you currently looking for a Epilepsy clinical trial? (Optional)
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Yes
No
Not Sure
Not Applicable
First Name
Last Name
Email
Phone (Optional)
Age (Optional)
Postal Code (Optional)
Gender (Optional)
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Male
Female
Transgender Male
Transgender Female
Gender Variant/Non-Conforming
Unspecified
How would you like to be contacted? (Optional)
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Phone Call
SMS
Text
Any
What would you like researchers to know about your experience with Epilepsy? (Optional)
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