Seizure Event Diary

Seizure Event Diary

Based on © 2019 Epilepsy Foundation of America, Inc. My 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

Injury & Rescue
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 Event
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 Description