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Name of person living with epilepsy:
Date of birth:
Date plan written:
Date to review:
1. General information
Medication records located:
Seizure 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)
of seizure
Usual frequency
of seizure
(state in terms
of seizures per
month, per year
or per day)
Is emergency
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
If you are untrained in
emergency medication,
call ambulance when:
Australia wide epilepsy help line 1300 852 853
© Epilepsy Foundation 2013
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6. How I want to be supported during a seizure:
Specify the support needed during each of the different seizure types.
(If you are ever in doubt about my health during or after the seizure, call an ambulance)
7. My specific post-seizure support:
State how a support person would know when I have regained my usual awareness and how long it typically takes for me to fully
recover. How I want to be supported. Describe what my post seizure behaviour may look like.
8. My risk/safety alerts:
For example bathing, swimming, use of helmet, mobility following seizure.
What will reduce this risk for me?
9. Do I need additional overnight support? Yes No
If ‘yes’ describe:
This plan has been co-ordinated by:
Organisation (if any):
Telephone numbers:
Association with person: (For example treating doctor, parent,
key worker in group home, case manager)
Client/parent/guardian signature (if under age):
Endorsement by treating doctor:
Your doctor’s name:
Doctor’s signature: Insert jpeg here Date:
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