Seizure History Questionnaire Form
Use this form to document seizure history, triggers, treatment context, and basic contact details. Keep the title exactly as shown throughout the form.
Patient and Contact Details
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Seizure History
First Known Seizure Date or Approximate Timeframe
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Seizure Type or Observed Description
Please Select
Generalized tonic-clonic
Absence/staring spell
Focal/partial seizure
Atonic/drop attack
Myoclonic jerks
Unknown/unsure
Other
How Often Seizures Occur
Please Select
Multiple per day
Daily
Several times per week
Weekly
Monthly
Less than monthly
Unknown/unsure
Other
Date of Most Recent Seizure
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Triggers, Treatment, and Care Context
Known Seizure Triggers
Sleep deprivation
Stress
Missed medication
Flashing lights
Illness
Alcohol
Unknown
Other
Current Seizure Medication or Treatment Status
Please Select
None
Current medication
Other
Has a Neurologist or Treating Clinician
Yes
No
Additional Notes or Concerns
Submit Form
Should be Empty: