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- Seizure
Journal
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. Click here to Printer version.
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PERSONAL
INFORMATION
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| Name: |
| Age:
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| Person
to contact in case of emergency: |
| Phone
#: |
| Neurologist:
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| Phone
#: |
| Family
Doctor/Pediatrician: |
| Phone
#: |
| Allergies:
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SEIZURE
REPORT
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| TYPE
(name of seizure, if known): |
| BEFORE
(What was happening - How were you feeling?): |
| DURING
(How do you behave during a seizure - the more specific,
the better): |
| 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 dose it take you to fully
recover?) |
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SEIZURE
DIARY
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Sunday
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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ANTI-EPILEPTIC
DRUGS
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Drug
Name
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Dosage
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Date
drug started/stopped
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Notes/Special
Instructions
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OTHER
MEDICATIONS
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Drug
Name
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Dosage
(amount and # times/day)
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Date
started/stopped
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Reason
for Use
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POSSIBLE
SIDE EFFECTS
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Date
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Possible
side effects of Medications to ask Doctor about
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"TRIGGERS"
REPORT
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Date
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List
and Describe
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QUESTIONS
TO ASK MY DOCTOR
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