top of page

Seizure History Form

Date
Month
Day
Year

Seizure History

When did your pet first have a seizure?
Month
Day
Year
If your pet has more than one episode in 24hrs, how often does this occur?
If your pet is an unspayed female, do the seizures increase during her heat?
When do the episodes usually occur?
Do episodes consistently occur in association with any of the following?
Are episodes induced by any of the following?
Can you tell if your pet is about to have an episode?
Yes
No
Do you observe any of the following signs prior to an episode?

Seizure Description

Do all the episodes seem the same?
Yes
No
Do the legs become stiff?
Yes
No
Is one side of the body worse than the other?
Yes
No
What is the first thing that you observe at the start of the episode?
Chewing movements
Salivation
Head movements
Front limb movements
Back limb movements
Whole body collapse
Other
Do you see any of the following during the episode?
Is your pet responsive to you during the event?
Yes
No
Does your pet exhibit any of the following after the event?
Confusion
Wobbliness
Vision problems
Aggression
Other

Additional Information

Do you have video footage of an event?
Yes
No
Do you have a seizure diary for your pet?
Yes
No
Has your pet been started on anti-seizure medications?
Yes
No
If yes, has the seizure frequency and or severity improved?
Yes
No
Nt Applicable
If yes, have any of the following signs been noted?

Current Medications

Medication #1

Medication #2

Medication #3

Medication #4

bottom of page