EPILEPSY ASSOCIATION OF CALGARY

SEIZURES- BEFORE DURING & AFTER
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OBSERVING AND RECORDING SEIZURES

*Aids in Accurate Diagnosis *Assists in Seizurre control
*Alerts individuals (the person with epilepsy, family, staff) to events that may trigger or bring on a seizure
This form is for personal use in recording and observing seizures.
Please check off the appropriate information.

BEFORE  Before the seizure:
1.Did the person:
________*cry or yell
________*fall down
________*stare

2.Did the person notice any of these auras?
________*smell
________*visual disturbance (lights, images)
________*sound
________*funny sensation in the stomach

3.Did you see the onset of the seizure or did someone alert you?
________*yes
________*no, someone alerted me

FOR FURTHER DESCRIPTIONS:

Please refer to the Epilepsy Fact Sheet
"First Aid For Seizures"
Common Types of Seizures

DURING  During the seizure:
1.How long did the seizure last?
________*estimated minutes
________*actual minutes

2.Did the person:
________*wander around the room
________*stare for a few seconds, like daydreaming
________*fall suddenly to the floor

3.On which side of the body did the seizure start?
________*left
________*right
________*both
________*unknown

4.Did the person bite their tongue during the seizure?
________*yes, the saliva was bloody
________*no, the saliva was clear

5.What was the person's level of consciousness?
________*unconscious
________*dazed
________*alert

6.Did the person have a loss of bladder/bowel control?
________*yes
________*no

7.Was the person's:
*breathing
______*impaired
______*absent
*head or face
______*twitching or grimacing
______*up or down
______*extended or flexed
*eyes rolling
______*to the right
______*to the left
______*upwards
*arms or legs
______*rigid or jerking
______*equal and rhythmic
______*extended and flexing
*skin tone
______*pale or blue
______*cool or warm
______*clammy

AFTER
After the seizure ask how the person is feeling, and note the duration of any of the following (as applicable):

Was the person injured (i.e. injured in fall)?
_____________________________________________

Does the person fell fatigued, weak or sleepy?
______________________________________________

Does the person have a headache?
_______________________________

Can the person recall the seizure?
__________________________________

Does the person appear alert, drowsy or confused?
________________________________________________

Is there muscle tiredness or weakness specific to one side?
_________________________________________________

Date of seizure________________________
Time of Day____________________________
Location_______________________________

Further comments:
Before the seizure:_____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________________________________.
During the seizure:_____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____________________________________________.
After the seizure:______________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____________________________________________.
We suggest you offer this information to the person who had the seizure for their reference.
This form was completed by:


Name:__________________________