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• * Date of Birth Select month January February March April May June July August September October November December Select day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906
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  Please provide your phone number so we can contact you in case of scheduling changes. Also please provide the number of guests that will be attending with you.
• * For whom are you requesting information? Please select an option Myself My Son or Daughter (under age 18) My Son or Daughter (over age 18) A Spouse A Parent A Friend Other

* Please answer the following questions about your or your friend/loved one’s epilepsy….

1. Overall, how much of an impact does your or your friend/loved one’s epilepsy and/or seizures have on your/his/her personal life (ie, personal relationships, leisure, home life)?

1	2	3	4	5	6	7	8	9	10	11
No    Impact				Moderate Impact			Major    Impact

2. I constantly worry that I or my friend/loved one will hurt myself/herself/himself or others while having a seizure.

1	2	3	4	5	6	7	8	9	10	11
Totally    Disagree				Neither Agree Nor Disagree			Totally    Agree

3. I actively seek out information about new ways to cope with my or my friend/loved one’s epilepsy.

1	2	3	4	5	6	7	8	9	10	11
Totally    Disagree				Neither Agree Nor Disagree			Totally    Agree

4. How concerned are you, if at all, about the possibility of you or your friend/loved one having a seizure in the next 12 months?

1	2	3	4	5	6	7	8	9	10	11
Not at All				Somewhat			Extremely

5. How likely, if at all, do you think it is that you or your friend/loved one will be restricted from driving in the future due to epilepsy/seizures?

1	2	3	4	5	6	7	8	9	10	11
Not at All				Somewhat			Extremely

* Are you or a friend/loved one taking any of the following medications? (Check all that apply.)

Prescription Medication

Depakote ER^® (divalproex sodium)
Depakote^® (divalproex sodium)
Dilantin^® (phenytoin)
Keppra^® (levetiracetam)
Lamictal^® (lamotrigine)
Lyrica^® (pregabalin)
Neurontin^® (gabapentin)
Phenobarbital
Tegretol XR^® (carbamazepine)
Tegretol^® (carbamazepine)
Topamax^® (topiramate)
Trileptal^® (oxcarbazepine)
Zonegran^® (zonisamide)
Other medication
I am not taking any prescription medications

How long have you or your friend/loved one been taking Keppra? Please Select Less than 1 week Between 1 week and 3 months Between 3-6 months Between 6-12 months Between 1-3 years More than 3 years

By providing this information, I give UCB, Inc. permission to send me information about epilepsy medication and other similar products from UCB, Inc. and its business partners. I understand that UCB Inc. or its business partners will not sell or transfer my name, address, e-mail address or any other information to any other party for their own marketing use. I can remove myself from the mailing list at any time by clicking here or by clicking Unsubscribe on the e-Newsletters that I will receive. Please review the privacy policy of UCB Inc.

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