Diagnosis form
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Name
Are you an infant, a child or an adult?
infant
child
adult
Exactly what happened during the episode/attack?
Indescribable feeling [dejavu feeling or smell/taste something absent]
Bief loss of awareness and stare in space
Black out with sudden stiff movements
Muscle's suddenly loses strength, may fall over
Rythmic jerking of arms and legs
Twitches on one side of the body
Black out , rythmic jerking of arms and legs ,stiff muscles
What could have triggered the episode/attack?
sleep deprivation
Exhaustion/Stress/Overtired
Alcohol abuse
Unknown
Was there a warning before episode/attack?
yes
no
How long did the episode/attack last?
less than a minute
1-3 minutes
5 mins and more
What time of the day did the episode/attack come?
Asleep
Awake
How frequent do the episodes occur?
Once
Frequent
Rare
Diagonise
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