The Seizure Journal is a resource for you and your doctor to keep track of important information including: seizure descriptions, seizure frequency, time of day seizures occur, triggers, medications, possible side effects, etc.
Your Journal is set-up with the following sections: Seizure Report, Seizure Diary, Medications, Trigger Report and Questions for Your Doctor.
| PERSONAL INFORMATION |
| Name: |
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| Age: |
| Person to contact in case of emergency: |
| Phone #: |
| Neurologist: |
| Phone #: |
| Family Doctor/Pediatrician: |
| Phone #: |
| Allergies |
| SEIZURE REPORT |
| TYPE (name of seizure, if known): |
BEFORE (What was happening - How were you feeling?):
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DURING (How do you behave during a seizure - the more specific, the better):
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| Average Duration: ___________(Minutes) |
AFTER (Are you confused?. . . For how long? Do you sleep?. . . For how long? Do you feel weak? How? Can you remember what happened during your seizure? How long does it take you to fully recover?)
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| SEIZURE DIARY |
| Sunday |
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
Saturaday |
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| ANTI-EPILEPTIC DRUGS |
| Drug Name |
Dosage |
Date drug started/stopped |
Notes/Special Instructions |
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| OTHER MEDICATIONS |
| Drug Name |
Dosage (amount
and # times/day) |
Date started/
stopped |
Reason for use |
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| "TRIGGERS" REPORT |
| Date |
List and describe |
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| QUESTIONS TO ASK MY DOCTOR |
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For a printable version of the Seizure Journal in Microsoft Word format please click the following link:
Seizure Journal
