The Epilepsy Association of Calgary
SEIZURES - BEFORE, DURING & AFTER
PRINT-OUT FORM
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.
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:__________________________
