* = Required Information
Individual:
*
Type of report:
A report of one seizure
A summary of seizures
Seizure was not witnessed
Number of Summary seizure
Date seizure occurred:
Time:
Location seizure occurred:
Length of seizure:
Staff Name:
PRIOR TO SEIZURE
Individual reported unusual feelings or physical symptoms
Describe:
Recent changes in medication or missed doses:
Describe what was happening immediately prior to the seizure occurring:
List any out of the ordinary stresses:
Date of last menses:
Other comments:
(Please complete the Seizure Observation Chart on the reverse side of this form)
SEIZURE OBSERVATION CHART
Check and complete all that apply
Prior to and during the seizure:
Individual fell
Individual called out before falling
Individual injured self while falling
where?
Individua4 seemed unaware of surroundings for a short time, but did not fall
Body was rigid
Individual was completely unconscious
Body jerked or convulsed.
For how long?
minutes
seconds
Individual had saliva accumulation at the mouth
Individual bit tongue; blood at the mouth
Face was very pale
Face cyanosed or blue.
Eyes rolled upward
Describe
Individual stared blankly into space
Individual repeated a movement or action
Individual mumbled or repeated a phrase
Individual abruptly stopped what they were doing, did not respond to questions or directions for a short time, then resumed normal activity without being aware of any interruption
Individual seemed dazed and/or confused and was unaware of their actions
Individual suddenly began to act strangely or had unusual behavior(s).
what did they do?
A muscle group on just one side of the body convulsed.
what muscle group and on what side of the body?
Individual was aware of this muscle movement but was unable to prevent it
List any other unusual physical movements:
After the seizure:
Individual slept
how long?
Individual quickly recovered, but seemed dazed
Individual resumed normal activities.
how long after the seizure activity?
Individual complained of a headache or other physical symptoms after seizure.
what was the complaint?
Incontinent of bladder
Incontinent of bowel
Comments:
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