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 @ |

Log multiple similar events below-

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |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 @ |

Log multiple similar events below-

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

|Date:_______________Time:_________________Length:____min. ____sec. |

|Mood: ο Good ο Normal ο Bad |ο Entered @ |

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