Keppra® - Patient and Caregivers

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Signing up for the Keppra.com e-Newsletter is another great step toward living Life on Your Terms™. Join now, and you’ll receive e-mail updates from Keppra.com that include helpful online tools, community resources and up-to-date information on living with epilepsy. It’s a great way to stay active in the epilepsy community and stay informed of the latest information on diagnosis and treatment.

We are committed to protecting your privacy. Please see the UCB, Inc. Privacy Policy.

To sign up, please provide the following information and click on the "Submit" link at the bottom of this page.

*Required information

*First Name:

*Last Name:

*E-mail Address:

Address 1:

Address 2:

City

State

*Zip

Gender

Date of Birth

*For whom are you requesting information?

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

1. Overall, how much of an impact does you 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 your friend/loved one taking any of the following medications? (Check all that apply.)

Prescription Medication
Depakote ER^® (valproic acid)
Depakote^® (valproic acid)
Dilantin^® (phenytoin)
Keppra^® (levetiracetam)
Lamictal^® (lamotrigine)
Lyrica^® (pregabalin)
Neurontin^® (gabapentin)
Phenobarbital
Tegretol XR^® (carbamazephine)
Tegretol^® (carbamazepine)
Topamax^® (topiramate)
Trileptal^® (oxcarbazepine)
Zonegran^® (zonisamide)
Other medication
Not taking any prescription medications

Yes, I want to receive e-Newsletters and information about Keppra^® and other product updates. By checking this box, I give UCB, Inc. permission to send the e-Newsletters and other product updates to me.

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Depakote and Depakote ER are registered trademarks of Abbott Laboratories.
Dilantin is a registered trademark of Pfizer Inc.
Keppra is a registered trademark of UCB S.A.
Lamictal is a registered trademark of GlaxoSmithKline.
Lyrica is a registered trademark of Pfizer Inc.
Neurontin is a registered trademark of Pfizer Inc.
Tegretol and Tegretol XR are registered trademarks of Novartis Pharmaceuticals Corporation.
Topamax is a registered trademark of Ortho-McNeil Neurologics, Inc.
Trileptal is a registered trademark of Novartis Pharmaceuticals Corporation.
Zonegran is a registered trademark of Dainippon Pharmaceutical Co. Ltd. and licensed exclusively to Eisai Inc.