Seizure Report Form Seizure Report v5 Fields marked with an * are required Client's Code (ALL CAPS!) * 5 of 5 Character(s) left IC Client's Name Support Worker's Name * Other Support Workers Date * Start Time - End Time During the Seizure was the person: standing remained standing lying in bed or asleep was sitting down Other What happens during the Seizure Goes stiff/rigid Smacking of lips Kicks and Twitches Repetitive movements Remained upright Fell down Staring Pulls or picks at clothing The person is: Conscious Semi-Conscious Unconscious Does the person Go pale in the face Pass urine Go blue in the face Sweat excessively Is the Seizure: Continuous Intermittent Duration of the Seizure: After the seizure has ended Person was Sleepy or sleeping Person was Dazed & Confused An Ambulance was called Incident or Injury (complete the Incident Report form) Behaviour as normal Ambulance Arrived Recovery time Comments If you are a human seeing this field, please leave it empty.
