Date:___________Time:___________Length:____min
Date:___________Time:___________Length:____min. ____sec. |( Flag It | |
|Type: ο Simple Partial ο Complex Partial ο Secondary Generalized ο Atonic |
|ο Tonic ο Clonic ο Tonic-Clonic ο Myoclonic οAtypical Absence |
|ο Absence ο Infantile Spasms (cluster) ο Unknown |
|Mood: ο Good ο Normal ο Bad |OTC Medications________________________ |
|Possible Triggers: |ο Changes in Medication (including late or missed) |
|ο Overtired or irregular sleep ο Alcohol or drug use ο Irregular Diet |
|ο Bright or flashing lights ο Fever or overheated ο Emotional Stress |
|ο Hormonal fluctuations ο Sick – Describe__________________________ |
|ο Other____________________ | |
|Trigger notes:_____________________________________________________ |
|Description: |ο Change in awareness ο Loss of urine or bowel control |
|ο Loss of ability to communicate |ο Automatic repeated movements |
|ο Muscle stiffness in________________ |ο Aura |
|ο Muscle twitch in_________________ |ο Other_____________________ |
|Description notes:__________________________________________________ |
|Post event: |ο Unable to communicate ο Remembers event |
|ο Sleepy |ο Muscle weakness |ο Sleepy |
|Post event notes:___________________________________________________ |
|ο Entered @ |
|Date:___________Time:___________Length:____min. ____sec. |( Flag It |
|Type: ο Simple Partial ο Complex Partial ο Secondary Generalized ο Atonic |
|ο Tonic ο Clonic ο Tonic-Clonic ο Myoclonic οAtypical Absence |
|ο Absence ο Infantile Spasms (cluster) ο Unknown |
|Mood: ο Good ο Normal ο Bad |OTC Medications________________________ |
|Possible Triggers: |ο Changes in Medication (including late or missed) |
|ο Overtired or irregular sleep ο Alcohol or drug use ο Irregular Diet |
|ο Bright or flashing lights ο Fever or overheated ο Emotional Stress |
|ο Hormonal fluctuations ο Sick – Describe__________________________ |
|ο Other____________________ | |
|Trigger notes:_____________________________________________________ |
|Description: |ο Change in awareness ο Loss of urine or bowel control |
|ο Loss of ability to communicate |ο Automatic repeated movements |
|ο Muscle stiffness in________________ |ο Aura |
|ο Muscle twitch in_________________ |ο Other_____________________ |
|Description notes:__________________________________________________ |
|Post event: |ο Unable to communicate ο Remembers event |
|ο Sleepy |ο Muscle weakness |ο Sleepy |
|Post event notes:___________________________________________________ |
|ο Entered @ |
2008 (
|Date:___________Time:___________Length:____min. ____sec. |( Flag It |
|Type: ο Simple Partial ο Complex Partial ο Secondary Generalized ο Atonic |
|ο Tonic ο Clonic ο Tonic-Clonic ο Myoclonic οAtypical Absence |
|ο Absence ο Infantile Spasms (cluster) ο Unknown |
|Mood: ο Good ο Normal ο Bad |OTC Medications________________________ |
|Possible Triggers: |ο Changes in Medication (including late or missed) |
|ο Overtired or irregular sleep ο Alcohol or drug use ο Irregular Diet |
|ο Bright or flashing lights ο Fever or overheated ο Emotional Stress |
|ο Hormonal fluctuations ο Sick – Describe__________________________ |
|ο Other____________________ | |
|Trigger notes:_____________________________________________________ |
|Description: |ο Change in awareness ο Loss of urine or bowel control |
|ο Loss of ability to communicate |ο Automatic repeated movements |
|ο Muscle stiffness in________________ |ο Aura |
|ο Muscle twitch in_________________ |ο Other_____________________ |
|Description notes:__________________________________________________ |
|Post event: |ο Unable to communicate ο Remembers event |
|ο Sleepy |ο Muscle weakness |ο Sleepy |
|Post event notes:___________________________________________________ |
|ο Entered @ |
|Date:___________Time:___________Length:____min. ____sec. |( Flag It |
|Type: ο Simple Partial ο Complex Partial ο Secondary Generalized ο Atonic |
|ο Tonic ο Clonic ο Tonic-Clonic ο Myoclonic οAtypical Absence |
|ο Absence ο Infantile Spasms (cluster) ο Unknown |
|Mood: ο Good ο Normal ο Bad |OTC Medications________________________ |
|Possible Triggers: |ο Changes in Medication (including late or missed) |
|ο Overtired or irregular sleep ο Alcohol or drug use ο Irregular Diet |
|ο Bright or flashing lights ο Fever or overheated ο Emotional Stress |
|ο Hormonal fluctuations ο Sick – Describe__________________________ |
|ο Other____________________ | |
|Trigger notes:_____________________________________________________ |
|Description: |ο Change in awareness ο Loss of urine or bowel control |
|ο Loss of ability to communicate |ο Automatic repeated movements |
|ο Muscle stiffness in________________ |ο Aura |
|ο Muscle twitch in_________________ |ο Other_____________________ |
|Description notes:__________________________________________________ |
|Post event: |ο Unable to communicate ο Remembers event |
|ο Sleepy |ο Muscle weakness |ο Sleepy |
|Post event notes:___________________________________________________ |
|ο Entered @ |
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