DiaryTracking MY

MY TRACKING DIARY

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ACTION CONTRE L’ÉPILEPSIE MD

TAKING ACTION AGAINST EPILEPSY

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TABLE OF CONTENTS

Contact Information .............................................................................................................................................2

Welcome to Your Seizure Tracking Diary ...................................................................................4

My Medications ..........................................................................................................................................................5

My Medication Log ................................................................................................................................................6

My Seizures .................................................................................................................................................................10

Seizure Tracking Diary .................................................................................................................................... 11

Setting Goals ............................................................................................................................................................22

Medical Appointment Notes .................................................................................24

Appendix ...............................................................................................................................26

CONTACT INFORMATION

PERSONAL

Name: ________________________________________________________________________

Phone: _______________________________________________________________________

Email: ________________________________________________________________________

MAIN CAREGIVER/COMPANION

Name: ________________________________________________________________________

Phone: _______________________________________________________________________

Email: ________________________________________________________________________

FAMILY PHYSICIAN

Name: ________________________________________________________________________

Phone: _______________________________________________________________________

Email: ________________________________________________________________________

NEUROLOGIST/EPILEPTOLOGIST

Name: ________________________________________________________________________

Phone: _______________________________________________________________________

Email: ________________________________________________________________________

EMERGENCY CONTACT

Name: ________________________________________________________________________

Phone: _______________________________________________________________________

Email: ________________________________________________________________________

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MY MEDICATIONS

WHY SHOULD I KEEP A MEDICATION LOG?

You can take action in managing your treatment by keeping an up-to-date record of your current medications (including prescribed medicines, over-the-counter medications and any vitamin/herbal supplements you are taking). This will help your healthcare team to understand your medication schedule and help them to predict possible side effects and drug interactions.

When discussing your treatment, you should keep a record of:

• The name of the medication

• The time of day you should take your medicatione.g. once in the morning, once in the evening, or at the same times each day

• The dose you should take e.g. 50 mg in the morning, 50 mg in the evening

• Any side effects that you may experiencei.e. all expected or unexpected side effects

HOW SHOULD I RECORD MY MEDICATION REGIMEN?

In this section of your booklet, you can take the opportunity to record some information about the medications that you take regularly (for epilepsy and other conditions).

We suggest that you include any special instructions or comments provided by your healthcare team in the comment box (e.g. “take this drug with food”).

Note that “Other Medications” should include all vitamin and herbal supplements, over-the-counter (OTC) medications and prescribed medications that are not anti-epileptic therapies.

WELCOME TO YOUR SEIZURE TRACKING DIARY

THIS TOOL WILL HELP YOU TRACK IMPORTANT INFORMATION RELATING TO YOUR SEIZURES.

Since your seizures usually won’t occur in your healthcare team’s offi ce, it’s important to give them as much information about your seizures as you can. Recording what happens between appointments can help them to understand and spot trends in your seizure activity. It can also help them see how you’re responding to your current treatment. Remember, your healthcare team may only see you every 3-12 months, so keeping a record can be very helpful.

This booklet is designed to make this tracking process easier. You won’t fi nd it takes too much time. You can record your symptoms, how you’re feeling and whether you’ve had any seizures. You can also keep track of medications that you’re currently taking and any side effects that you may be experiencing.

Just remember to bring your log to all of your appointments!

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ANTI-EPILEPTIC MEDICATIONS

Medication Name What it’s used forNumber of tablets per dose, tablet strength and administration

# of doses per day

Total daily dose

Time of day taken (am/pm) Day started/day stopped (if known)

Example Medication Reducing seizure activity

One 10 mg capsule taken by mouth 2 20 mg 7am 7pm Started May 5, 2015

Stopped Jan 9, 2016

Notes/Special Instructions: Take with food (dairy)

Notes/Special Instructions:

Notes/Special Instructions:

Notes/Special Instructions:

Notes/Special Instructions:

Notes/Special Instructions:

MY MEDICATION LOGIt’s very important to remember to take your medication as prescribed

by your healthcare team. Remember – only your healthcare professional should decide if your dose should be adjusted. Do not stop taking your

medication without talking to your healthcare professional. Stopping your treatment suddenly can cause serious problems, including seizures that will not stop. Your healthcare professional will decide how long you should continue your treatment.

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OTHERMeds

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OTHER MEDICATIONS

Medication Name What it’s used forNumber of tablets per dose, tablet strength and administration

# of doses per day

Total daily dose

Time of day taken (am/pm) Day started/day stopped (if known)

Example Medication HEADACHES One 5 mg tablet taken by mouth 1 5 mg 8am Started FEB 10, 2010

STILL TAKING REGULARLY

Notes/Special Instructions: Take with food

Notes/Special Instructions:

Notes/Special Instructions:

Notes/Special Instructions:

Notes/Special Instructions:

Notes/Special Instructions:

Notes/Special Instructions:

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MY MEDICATION LOG

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SEIZURE TRACKING DIARY

Your Tracking Diary is an important part of monitoring your treatment therapy. This diary will help you to track how often you experience seizures, and important information about these events.

WHAT SHOULD I INCLUDE IN MY SEIZURE DESCRIPTIONS?

In the Appendix of this booklet (page 26), you’ll fi nd a list of symptoms, experiences and triggers that are commonly associated with partial-onset seizures. You can use these as examples while fi lling in your diary. However, please keep in mind that this is not an exhaustive list. If you have an experience not included in the list, please make sure to include this in your seizure description.

Try to include as much relevant information as possible, as this will help your healthcare team to spot trends and see how you are responding to your treatment.

MY SEIZURES

WHY IS IT IMPORTANT TO TRACK MY SEIZURE ACTIVITY?

Tracking your seizures will help you keep a record of:

• how often and when your seizures are happening

• how you were feeling/acting before, during and after your seizures

• the events that led up to your seizures

This record will help you and your healthcare team assess your progress (for example, changes in your seizure activity or how you are responding to treatment), so that you can ensure you are getting the best results.

To avoid forgetting important details, try to write about a seizure soon after you’ve experienced it. If you don’t remember details because of your seizure, try asking someone who witnessed it.

SEIZURE TRACKING

Date Date: August 19, 2016 Date: Date:

Did you take all of your epilepsy medications? Yes

How do you feel?Overall not feeling very well. Lightheaded and having difficulty focusing.

Did you have any seizures? Yes

How long did the seizure last? 30 seconds

How many seizures did you have? 1

What time of day did you have your seizure? 9 am

If known, what was the seizure type (i.e. name of seizure type)?

Simple partial seizure

Describe the symptoms and experiences associated with each seizure you had today.

BEFORE: - fully aware- felt anxious - had trouble speaking clearly (struggling to find the right words)

DURING: - periods of forgetfulness/ memory

lapse - felt afraid and sad - garbled speech

AFTER: - fully aware of my surroundings- tired

EFORE:

DURING:

AFTER:

EFORE:

DURING:

AFTER:

Did you experience any predicted triggers prior to your seizure?

Yes – I was around flashing lights

Do you feel like you are experiencing any side effects with your medication?

No

It’s also common to experience some minor side effects when starting a new medication. If you do happen to experience any possible side effects while beginning a new treatment therapy, please use this space to keep a record. It’s important that you talk to your healthcare team about any of these events.

Recording whether or not you’ve taken your medication each day is important, since this can help ensure that you don’t miss a dose. It can also help your healthcare team notice changes in your seizure activity caused by a forgotten dose.

Explaining how you feel on a day-to-day basis can help show patterns linked to your seizure activity, and could affect your treatment.

Indicating the number, type and frequency of your seizures is an important part of assessing your progress. It will also be useful to record the time of day at which you experienced them.

See the Appendix (page 26) for a list of examples of symptoms, experiences and triggers.

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SEIZURE TRACKING DIARYYou can use the charts below to keep a daily log of your seizure

activity, medications and any adverse events. Below is an example of a chart entry for one day.

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SEIZURE TRACKING

Date Date: Date: Date:

Did you take all of your epilepsy medications?

How do you feel?

Did you have any seizures?

How long did the seizure last?

How many seizures did you have?

What time of day did you have your seizure?

If known, what was the seizure type (i.e. name of seizure type)?

Describe the symptoms and experiences associated with each seizure you had today.

BEFORE:

DURING:

AFTER:

BEFORE:

DURING:

AFTER:

BEFORE:

DURING:

AFTER:

Did you experience any predicted triggers prior to your seizure?

Do you feel like you are experiencing any side effects with your medication?

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SEIZURE TRACKING

Date Date: Date: Date:

Did you take all of your epilepsy medications?

How do you feel?

Did you have any seizures?

How long did the seizure last?

How many seizures did you have?

What time of day did you have your seizure?

If known, what was the seizure type (i.e. name of seizure type)?

Describe the symptoms and experiences associated with each seizure you had today.

BEFORE:

DURING:

AFTER:

BEFORE:

DURING:

AFTER:

BEFORE:

DURING:

AFTER:

Did you experience any predicted triggers prior to your seizure?

Do you feel like you are experiencing any side effects with your medication?

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SEIZURE TRACKING

Date Date: Date: Date:

Did you take all of your epilepsy medications?

How do you feel?

Did you have any seizures?

How long did the seizure last?

How many seizures did you have?

What time of day did you have your seizure?

If known, what was the seizure type (i.e. name of seizure type)?

Describe the symptoms and experiences associated with each seizure you had today.

BEFORE:

DURING:

AFTER:

BEFORE:

DURING:

AFTER:

BEFORE:

DURING:

AFTER:

Did you experience any predicted triggers prior to your seizure?

Do you feel like you are experiencing any side effects with your medication?

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SEIZURE TRACKING

Date Date: Date: Date:

Did you take all of your epilepsy medications?

How do you feel?

Did you have any seizures?

How long did the seizure last?

How many seizures did you have?

What time of day did you have your seizure?

If known, what was the seizure type (i.e. name of seizure type)?

Describe the symptoms and experiences associated with each seizure you had today.

BEFORE:

DURING:

AFTER:

BEFORE:

DURING:

AFTER:

BEFORE:

DURING:

AFTER:

Did you experience any predicted triggers prior to your seizure?

Do you feel like you are experiencing any side effects with your medication?

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Realistic goals can be important milestones that can help you stay focused and positive. The lists below will allow you to explore some common interests shared by many people with epilepsy. You can take an active role in your epilepsy management by choosing which goals you are most interested in working towards.

SETTING GOALS Setting goals for yourself is an important part of your treatment journey.

After all, it can be motivating to have something to work towards!

Some goals you might consider:

• Leading a healthier lifestyle by improving your diet and exercise schedule.

• Reducing your stress by practicing yoga or meditation.

• Getting a good night’s sleep by creating a better sleep environment.

I WANT TO FEEL:

Independent

Safe

Positive about my treatment

In control of my life

Less anxious or depressed

I WANT MY TREATMENTS TO:

Start working sooner

Fit into my life

Reduce my seizures

Have a simple dosing schedule

Cause fewer short-term side effects

Cause fewer long-term side effects

I WANT TO LOOK FORWARD TO:

Fewer restrictions on my activities

The future

Travelling

Social activities

Overcoming daily challenges

Better relationships with family and friends

If you have additional goals that you are interested in working towards, you can record them here:

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MEDICAL APPOINTMENT NOTES This space may be used to record any questions for your healthcare team or notes about your medical appointments.

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APPENDIX

WHAT SHOULD I INCLUDE IN MY SEIZURE DESCRIPTIONS?

BEFORE THE SEIZURE

Physical and Sensory Symptoms Unusual taste (e.g. metallic)

Unusual smell (e.g. chemical)

Hearing sounds (i.e. voices or buzzing)

Vision abnormalities (i.e. loss of vision, blurring, fl ashing lights)

Tingling, pins and needles, or numbness in parts of the body

Feeling anxiety or fear

Chest/stomach discomfort

Nausea

Déjà vu (feeling you’ve been in a similar situation before)

Jamais vu (feeling something is familiar, but it isn’t)

DURING THE SEIZURE

Responsiveness Fully aware

Confused

Distracted/daydreaming

Responds to touch

Responds to voice

Periods of forgetfulness/memory lapse

Not responsive

Sensations Hearing sounds differently

Unusual smells

Unusual tastes

Vision abnormalities (i.e. loss of vision, blurring, fl ashing lights, hallucinations)

Tingling, pins and needles, or numbness in parts of the body

Anxiety/fear

Out-of-body or detached feeling

Déjà vu (feeling you’ve been in a similar situation before)

Jamais vu (feeling something is familiar, but it isn’t)

Physical symptoms Abnormal facial expressions (i.e. staring, twitching, eyes rolling, eyes blinking)

Abnormal head movements (i.e. sudden head drop, turns side to side, or turns to one side)

Body stiffness (i.e. whole body, just legs, just arms)

Jerking movements (i.e. whole body, just legs, just arms)

Automatic movements (i.e. hand clapping or rubbing, lip smacking, chewing, walking, wandering, running)

Speech abnormalities (i.e. unable to talk, mixing up words, incoherent/nonsense words)

Falls

Injury/type of injury

Incontinent

AFTER THE SEIZURE

Responsiveness Fully aware

Confused

Tired

Irritable/agitated

Asleep

COMMONLY REPORTED TRIGGERS

Specifi c time of day or night

Lack of sleep

Illness (e.g. fever)

Flashing lights/patterns

Alcohol/drug use

Stress

Hormonal changes (e.g. menstrual cycle)

Low blood sugar/unusual eating habits

Consuming certain foods (e.g. caffeine)

Use of certain medications

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UCB and UCB logo are registered trademarks of the UCB group of companies.

© 2017 UCB Canada Inc. All rights reserved.

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ACTION CONTRE L’ÉPILEPSIE MD

TAKING ACTION AGAINST EPILEPSY

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