Seizure Report Form
Staff Name
*
First Name
Last Name
Participant Name
*
First Name
Last Name
Date
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Seizure Length
*
Location
*
Seizure Type
*
Simple Partial
Atonic
Tonic-Clonic
Absence
Complex partial
Tonic
Myoclonic
Atypical Absence
Secondary Generalised
Clonic
Infantile Spasms (cluster)
Unknown
Possible Triggers
*
Med change (inc. late or missed)
Emotional Stress
Irregular Diet
Fever/ overheated
Tires/irregular sleep
Hormonal fluctuations
Alcohol/ drug use
Bright/ flashing lights
Sick
Other
Please write what activity the participant was engaged with prior to the seizure:
*
Description of Symptoms
*
Change in awareness
Automatic movements
Loss of ability to communicate
Muscle twitching
Loss of urine/bowel control
Muscle stiffness
Had an aura
Other
Notes
Post Event
*
Unable to communicate
Muscle weakness
Fatigued
Falls Asleep
Unregulated
Unsettled
Injury
Confusion
Other
Notes
Did the participant require hospitalisation post seizure?
*
Yes
No
Submit
Should be Empty: