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Name of person living with epilepsy:
1. General information
Medication records located:
General support needs document located:
Epilepsy diagnosis (if known):
2. Has emergency epilepsy medication been prescribed? Yes No
If yes, the medication authority or emergency medication plan must be attached and followed*, if you are specifically trained.
These documents are located:
3. My seizures are triggered by: (if not known, write no known triggers)
4. Changes in my behaviour that may indicate a seizure could occur:
(For example pacing, sad, irritability, poor appetite, usually very mobile but now sitting quietly)
5. My seizure description and seizure support needs:
(Complete a separate row for each type of seizure – use brief, concise language to describe each seizure type.)
Description of seizure
(Make sure you describe what the
person looks like before, during
and after and if they typically occur
in a cluster)
Typical
duration
of seizure
(seconds/
minutes)
Usual frequency
of seizure
(state in terms
of seizures per
month, per year
Is emergency
medication
prescribed
for this type
of seizure?
When to call an ambulance
If you are trained in emergency
medication administration* refer
to the emergency medication plan
and the medication authority
No
emergency medication,
call ambulance when:
