DREAM Forms

Form Id: EVN_CHR_EPI

GENERAL INFORMATION AND MEDICAL HISTORY
Age of onset of seizures:
The description of the seizures was collected from the patient ?:
The description of the seizures was collected from the guardian/companion?:
Consciousness: meaning of the term and explanatory notes
* Patient with total loss of consciousness:
- is unable to remember what happens in this phase
* Patient with reduced/altered consciousness:
- is unable to correctly remember everything that happens during this phase. Or:
- The patient only partially remembers what happens during this phase.
* Patient with normal consciousness:
- remember well everything that happens during this phase: therefore there is no loss of consciousness
Crisis information and description
Is there a total loss of consciousness?:
Is there a partial loss or alteration of consciousness?:
Before total loss of consciousness
Sudden and unexplained change in behavior:
Does the patient suddenly exhibit aggressive behavior?:
Does the patient experience inexplicable emotions, such as fear or sensations of dreaming?:
Involuntary movements such as jerking/twitching of the limbs?:
Does the patient experience pins and needles sensations or abnormal sensitivity in one or more parts of the body?:
Loud scream:
Headache:
The patient has visual hallucinations (sees images that are not there)?:
The patient has auditory hallucinations (hears sounds/voices that are not there)?:
The patient has olfactory hallucinations (smells things that are not there)?:
The patient has abdominal pain, stomach sensation and/or discomfort?:
The patient has palpitations?:
The patient speaks involuntarily and/or speaks strange words?:
Does the patient fall to the ground before losing consciousness? (If YES, the patient can remember falling):
Other:
During total loss of consciousness
How long does the loss of consciousness last?:
Does the patient falls ? (If YES: the patient is NOT able to remember falling):
Involuntary movements such as jerking/twitching of the limbs?:
Whole body stiffness?:
Salivation?:
Tongue bite?:
Blood in the mouth?:
Loss of urine?:
Loss of feces?:
Other:
Reduced consciousness or altered consciousness
Sudden and unexplained change in behavior?:
Does the patient suddenly exhibit aggressive behavior?:
Does the patient experience inexplicable emotions, such as fear or sensations of dreaming?:
Involuntary movements such as jerking/twitching of the limbs?:
Does the patient experience pins and needles sensations or abnormal sensitivity in one or more parts of the body?:
Headache:
The patient has visual hallucinations (sees images that are not there)?:
The patient has auditory hallucinations (hears sounds/voices that are not there)?:
The patient has olfactory hallucinations (smells things that are not there)?:
Does the patient have abdominal pain, sensations and/or discomfort in the stomach and/or abdomen?:
The patient has palpitations?:
The patient speaks involuntarily and/or speaks strange words?:
Does the patient fall to the ground?:
Patient with normal consciousness:
Involuntary movements such as jerking/twitching of the limbs?:
Does the patient experience pins and needles sensations or abnormal sensitivity in one or more parts of the body?:
The patient speaks involuntarily and/or speaks strange words?:
Does the patient fall to the ground?:
Sudden and unexplained change in behavior:
In any case
Remember that when the epileptic seizure does not start immediately with the loss of consciousness but is preceded by a phase of
reduction/ALTERATION of consciousness (even if the latter is brief) the duration of the seizure must include:
- BOTH the phase preceding the total loss of consciousness, i.e. when it starts with a reduction/ALTERATION of consciousness (if present)
- AND the total loss of consciousness
Duration of the entire seizure:
Time required for the patient to regain normal consciousness::
Frequency of crises:
Total number of crises in the last 3 months:
Number of seizures in the last month::
Date of last seizure::
Are there seizures during sleep?:
Factors that trigger crises::

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