Seizure Event Diary

Please use this form to record all seizure events to the best of your ability. With regular use, this data builds a more complete picture of your day-to-day circumstance and helps us to better substantiate and communicate your needs to other healthcare providers and your insurance.
Your Name *

First NameLast Name
Date and Event Start Time *

MonthDayYear
Date
Hour MinutesAM/PM Option
Seizure Description

For each category to describe your seizure event. CHOOSE ALL THAT APPLY
- Awareness*
  
  Fully AwareConfusedAble to respond to voiceUnable to respond to voiceDon't rememberOther
- Speech*
  
  Able to talk normallyUnable to talkIncoherent / Nonsense wordsMixing up wordsDon't rememberOther
- Facial Expressions*
  
  StaringTwitchingEyes rollingEyes blinkingDon't rememberNoneOther
- Head Movements*
  
  Sudden head dropTurns to one sideTurns side to sideStuck in one positionDon't rememberNoneOther
- Body Stiffness*
  
  Whole bodyLegsArmsHandsDon't rememberNoneOther
- Jerking Movements*
  
  Whole bodyLegsArmsDon't rememberNoneOther
- Automatic Movements*
  
  Hand clapping or rubbingLip smacking / chewingWalking or WanderingRunningDon't rememberNoneOther
- Did you fall or were you injured ?*
  
  NoMild injury or bruise - WITH FallMild injury or bruise - NO FallSevere injury or hurt - WITH FallSevere injury or hurt - NO Fall
- Describe injury - including location(s) and actions taken
- Was rescue medication given?*
  
  YesNo
- Name of rescue medication given
- After the seizure - how were you?*
  
  Fully awareResponding normallyConfusedTiredAsleepAgitated / IrritableIncontinent (check for yes)Other
- How long did the seizure last? (in minutes) *
- How long did it take to recover? (in minutes)
- What triggers may have contributed to the event?
  Ex: lack of sleep, stress, emotional situation, alcohol, medication change, menstruation, specific foods... etc.
- Who was with you when it happened?
- Any other notes on the event?
  Ex: Where were you? Any new or unusual occurrences
- Should be Empty:

Seizure Event Diary

Seizure Description