Epilepsy Survey for Patients, Physicians, Caregivers, and General public

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Please answer the following questions to help us better understand your experience with or understanding of epilepsy. Your responses will remain confidential and will be used for research purposes only.

Your name *

Your ethnicity *

Caucasian/White

Black or African American

Hispanic or Latino

Asian or Asian American

Native American or Alaska Native

Native Hawaiian or Other Pacific Islander

Mixed or Multiracial

Other:

If you answered 'other', please specify your answer here:

Your Country *

USA

Your State or Territory *

Your City *

Your Area Zipcode *

Which of the following best describes your role or relationship in relation to epilepsy? Please select one option:
*

Patient diagnosed with epilepsy

Physician or healthcare professional treating patients with epilepsy

Caregiver providing support to someone with epilepsy

Member of the general public interested in learning more about epilepsy

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