Seizure Report Logout REF No: Log No/ Initials of affected party/ DD/MM/YYSeizure ReportName of person we support First Last Location Date of Incident Day Month Year Time Hours : Minutes AM PM AM/PM Was there any warning prior to the seizure? Change of Mood Restlessness Sensations Sound Other If "Other", Please give details below:Were they Standing Sitting In bed Unobserved Seizure Other If "Other", Please give details below:What were they doing prior to seizure?Did they fall? Forward Backward N/A Did they stiffen? Yes No Was there loss of consciousness? Yes No Did their colour change? Yes No If yes, describe colourWas there movement? Yes No Parts of the body involved Left Right Both sides Arms Legs Picking/fumbling of clothes Eyelid flutters/blinking Spasmodic jerking of arms Facial movements Eyes turning Stiffening of arms Stiffening of legs Spasmodic jerking of legs Blank stare/absence Tremors Other If "Other", describe belowWas there difficulty breathing? Yes No How long did the seizure last?Was there incontinence? Yes No What was the person's condition after seizure? Confused Agitated Other Length of RecoveryDid the person suffer any injury? Yes No TreatmentWere there any triggers? Stress Illness Unusual exercise/experience Medication Other If "Other", please specify belowReported By First Last Date MM slash DD slash YYYY
