Report of Possible Seizure Activity
Student: Program/Cottage: Date: Time: AM/PM
Staff Reporting: Did the student go to the ER? ☐ yes ☐ no If yes, why:
Brief Description of Seizure:
Did Reporter see the beginning of the seizure? ☐ yes ☐ no Where did the seizure take place:
Total time of seizure activity: ☐seconds ☐minutes Activities/Behaviors before the seizure started:
Student’s behavior after the seizure: ☐ slept, if so for how long ☐ tired ☐ agitated ☐ normal ☐ other, describe
How long did the post-ictal (post-seizure) changes last?: ☐ minutes ☐ hours
Did the seizure result in injury? ☐ yes ☐ no If yes, describe:
Was a medication given to stop the seizure: ☐ Diastat ☐ Ativan ☐ Other Did the seizure stop after the med? ☐ yes ☐ no
Please check your observations below, where appropriate check R, L, or Both:
Body
☐ Normal
☐ Stiffen
☐ Slumped forward
☐ Fell backward
☐ Fell to floor
☐ Shaking
Head
☐ Normal
☐ Dropped forward
☐ Dropped backward
☐ Shaking
☐ Turns (R or L)
Facial Color
☐ Normal
☐ Flushed
☐ Pale
☐ Cyanotic (blue)
Face
☐ Normal
☐ Distorted
☐ Stiff
☐ Twitching
Mouth
☐ Normal
☐ Contorted
☐ Twitching
☐ Repetitive Motions
☐ Excessive Secretions
☐ Other
Breathing
☐ Normal
☐ Labored
☐ Irregular
☐ Rapid
☐ Stopped: for how long?
Vocalizations
☐ None or normal
☐ Moaning
☐ Crying
☐ Laughing
☐ Screaming
☐ Strange words:
☐ Gibberish
Incontinence
☐ None
☐ Urine
☐ Feces
Arms ☐ R ☐ L ☐ Both
☐ Normal
☐ Shaking/twitching
☐ Stiff (R,L Both)
Hands ☐ R ☐ L ☐ Both
☐ Normal
☐ Shaking, twitching
☐ Stiff
☐ Other
Legs ☐ R ☐ L ☐ Both
☐ Normal
☐ Shaking, twitching
☐ Stiff
☐ Swinging
☐ Other
Other Observations or Unusual Behaviors: