Report A Seizure
Date of the seizure
*
/
Month
/
Day
Year
Time
AM
PM
AM/PM Option
Type of seizure
Generalized (grand mal)
Focal (partial)
Other
Were any additional medications given?
Midazolam (nasal)
Midazolam (injection)
Keppra
Phenobarbital
Other
Click to report additional seizures
Additional seizure (#2)
/
Month
/
Day
Year
Time Minutes
AM
PM
AM/PM Option
Type of seizure
Generalized (grand mal)
Focal (partial)
Other
Were any additional medications given?
Midazolam (nasal)
Midazolam (injection)
Other
Additional seizure (#3)
/
Month
/
Day
Year
Time Minutes
AM
PM
AM/PM Option
Type of seizure
Generalized (grand mal)
Focal (partial)
Other
Were any additional medications given?
Midazolam (nasal)
Midazolam (injection)
Other
Additional seizure (#4)
/
Month
/
Day
Year
Time Minutes
AM
PM
AM/PM Option
Type of seizure
Generalized (grand mal)
Focal (partial)
Other
Were any additional medications given?
Midazolam (nasal)
Midazolam (injection)
Other
Additional seizure (#5)
/
Month
/
Day
Year
Time Minutes
AM
PM
AM/PM Option
Type of seizure
Generalized (grand mal)
Focal (partial)
Other
Were any additional medications given?
Midazolam (nasal)
Midazolam (injection)
Other
Section Break (hidden)
Seizure severity
Mild
Medium
Severe
Other
Description of event *
Cluster-buster details (dose, frequency, duration)
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Date of the last seizure before this one (if known):
/
Month
/
Day
Year
Patient Information
Patient Name
*
Current daily medications, doses, and frequency. If your pet isn’t taking any, write N/A.
*
Concerning Side Effects (to help us decide if a dose increase is an option)
Has there been a recent change in medications or any missed doses?
Client Information
Client Name
First Name
Last Name
Email
*
Phone Number
Format: (000) 000-0000.
Would you like to be contacted about this seizure? *
*
Yes
No
If yes, what specific concerns would you like addressed?
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