Exit this survey MHNC1172~TEENS WITH PARTIAL ONSET SEIZURES 1. Question Title 1. Please complete the contact information below. First and Last Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title 2. Please supply us with a secondary contact number. Murray Hill Center standard policy requires at least two contact numbers for each respondent. If the secondary number you give us is not your own number but a friend, family member or co-worker please indicate as such. Question Title 3. What is your gender? Male Female Question Title 4. What is your current age? Question Title 5. What is your ethnicity? Caucasian African American / Black Asian American Indian / Native American Hispanic / Latino Other (please specify) Question Title 6. What is your current work status? Full-Time Employed Part-Time Employed Homemaker Unemployed / Looking for work Retired Student Full-Time Question Title 7. What is your Occupation-Job Title, Company you work for, and Industry? (If you are Retired, Unemployed or a Homemaker Please tell us your previous employment information. If you are a full-time student please enter your Grade, School and Major) Occupation: Company: Industry: Question Title 8. 8. What is the highest level of education that you have completed? Some High School or less High School Graduate or GED Some College - No degree 2 yr College Degree / Associates 4 yr College Degree / Bachelors Post Graduate Work / Degree Question Title 9. 9. What is your current marital status? Single - Never Married Single - Divorced Single - Widowed Single - Separated Live with Partner / Co-Hab Married Question Title 10. . Are you or is anyone in your immediate family currently employed by a pharmaceutical company, healthcare company, and marketing or marketing research company? YES NO Question Title 11. With which of the following conditions, if any, have you been diagnosed by a doctor? (Diagnosed here means that a physician has confirmed that you suffer from the condition) a. Migraine b. Epilepsy/Epileptic Seizures c. Juvenile Diabetes d. Rheumatoid Arthritis e. Cancer f. Sleep Disorder g. Anxiety Disorder h. None of the above Question Title 12. There are many different types of epilepsy. Which type of epilepsy or seizure disorder have you been diagnosed with? a. Generalized Seizure b. Partial Onset Seizure disorder (also known as focal seizure disorder) only c. Partial onset Seizure disorder (also known as focal seizure disorder) and generalized seizures Question Title 13. How long have you been diagnosed with Epilepsy and how long have you been diagnosed with partial onset seizure disorder (also known as focal seizure disorder) ________________________# Years with Epilepsy ________________________# Years with partial onset Disorder (also known as focal seizure disorder) Question Title 14. . What prescription medications (medications that must be obtained with a physician’s prescription) are you aware of for the treatment of Partial Onset Seizure disorder also known as focal seizure disorders associated with epilepsy? If you cannot think of any, please type “none.” Please list as many as you can think of. Aptiom® (eslicarbazepine acetate) Briviact® (brivaracetam) Depakote® (divalproex sodium) Dilantin® (phenytoin) Fycompa® (perampanel) Keppra® / Keppra® XR (levetiracetam) Lamictal® / Lamictal® XRTM (lamotrigine) Neurontin® (gabapentin) Oxtellar XRTM (extended release oxcarbazepine) Tegretol® / Tegretol® XR (carbamazepine) Topamax® (topiramate) Trileptal® (oxcarbazepine) Vimpat® (lacosamide) Question Title 15. Which of the following medications have you ever taken and which do you currently take for the treatment of Partial Onset Seizure disorder also known as focal seizure disorders associated with epilepsy? Aptiom® (eslicarbazepine acetate) Briviact® (brivaracetam) Depakote® (divalproex sodium) Dilantin® (phenytoin) Fycompa® (perampanel) Keppra® / Keppra® XR (levetiracetam) Lamictal® / Lamictal® XRTM (lamotrigine) Neurontin® (gabapentin) Oxtellar XRTM (extended release oxcarbazepine) Tegretol® / Tegretol® XR (carbamazepine) Topamax® (topiramate) Trileptal® (oxcarbazepine) Vimpat® (lacosamide) Question Title 16. You previously indicated that you are currently taking for your Partial Onset Seizure disorder also known as focal seizure disorders associated with epilepsy. For how long have you been taking each medication? Less than 4 months 4-12 months 1-2 years 2-5 years More than 5 years Question Title 17. How active do you consider yourself to be in researching your epilepsy/ seizure disorder diagnosis and/or treatment options? Please use a scale of 1 to 7 where “1” represents very inactive in researching the diagnosis and treatment options, and “7” represents very active in researching the diagnosis and treatment options. Question Title 18. Overall, how satisfied are you with your current medication for your partial onset seizures (also known as focal seizure disorder) associated with epilepsy? Please use a scale of 1 to 7 where “1” represents very dissatisfied with symptom control of your current medication, and “7” represents very satisfied with symptom control of your current medication Question Title 19. Do you have daily access to a computer with high-speed internet? YES NO Question Title 20. Again, using a scale of 1 – 10, where 1 is not at all comfortable and 10 is extremely comfortable; please tell me how comfortable you are with each of the following: Typing on a computer keyboard? Using e-mail? Conducting a basic internet search? Question Title 21. Do you have daily access to a computer with high speed internet? YES NO Question Title 22. If you qualify you log on at your convenience from home for about 60 minutes per day (for 3/4 days), to respond to and build on the day’s discussion. New questions will appear daily by 3:00 PM (EST). You will be provided with a pseudonym name so that you can feel free to comment honestly and openly. Your comments will not be attributed to you.Prior to the start of the online session, we will email you with instructions and provide you with the study link and your password. You will be contacted on the day before the VRT starts to confirm receipt of your instruction email. Are you will to participate fully? Yes No Next