Pediatric Absence Seizure Symptom and Trigger Log Form
Use this form to record details of absence seizure episodes in children, including symptoms, possible triggers, and actions taken.
Child Name or Identifier
*
Date of Episode
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Episode
*
Hour Minutes
AM
PM
AM/PM Option
Seizure Duration (minutes)
*
Symptoms / Episode Observations
*
Possible Trigger(s)
Lack of sleep
Stress or anxiety
Flashing lights
Missed medication
Illness/fever
Other
Activity Before Episode
Please Select
Sleeping
Eating
Watching TV or screen
Playing
Studying/at school
Other
Recovery Notes
Was medical attention sought?
Yes
No
Submit Log
Should be Empty: