Seizure Journal
(Printer version)

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:
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?):
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 does it take you to fully recover?)

 

SEIZURE DIARY
Date
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Date:____to:____              
Date:____to:____              
Date:____to:____              
Date:____to:____              

 

ANTI-EPILEPTIC DRUGS
Drug Name
Dosage
Date drug started/stopped
Notes/Special Instructions
       
       
     
     
       
       
     
     

 

OTHER MEDICATIONS
Drug Name
Dosage (amount and # times/day)
Date started/stopped
Reason for Use
       

 

POSSIBLE SIDE EFFECTS
Date
Possible side effects of Medications to ask Doctor about
   

 

"TRIGGERS" REPORT
Date
List and Describe
   

 

QUESTIONS TO ASK MY DOCTOR