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
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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 *
Additional Medication 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
Has there been a recent change in medications or any missed doses?
Client Information
Client Name
First Name
Last Name
Email
*
Phone Number
Would you like to be contacted about this seizure? *
*
Yes
No
If yes, what specific concerns would you like addressed?
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