Fillable SEIZURE ACTION PLAN FOR (INSERT NAME HERE)

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SEIZURE ACTION PLAN FOR (INSERT NAME HERE)

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ABOUT
______________________________________________________________________________________________________________________________________
Name Date of Birth
______________________________________________________________________________________________________________________________________
Doctors Name Phone
______________________________________________________________________________________________________________________________________
Emergency Contact Name Phone
______________________________________________________________________________________________________________________________________
Emergency Contact Name Phone
Seizure Type / Name:
_______________________________________________________________________________________________________________
What Happens:
____________________________________________________________________________________________________________________
How Long It Lasts
:
________________________________________________________________________________________________________________
How Often
:
________________________________________________________________________________________________________________________
Seizure Triggers:
Missed Medicine Lack of Sleep Emotional Stress Physical Stress Missing meals
Alcohol / Drugs Flashing Lights Menstrual Cycle Illness with high fever
Response to specific food, or excess caffeine Specify:
Other Specify:
DAILY TREATMENT PLAN
Seizure Medicine(s)
Name How Much How Often / When
Additional Treatment / Care: (i.e.: diet, sleep, devices etc.)
CAUTION – STEP UP TREATMENT
Symptoms that signal a seizure may be coming on and additional treatment may be needed:
Headache Staring Spells Confusion Dizziness Change in Vision / Auras
Sudden Feeling of Fear or Anxiety Other Specify:
Additional Treatment:
Continue Daily Treatment Plan
• If missed medicine, give prescribed dose from above ASAP.
• Do not give a double dose or give meds closer than 6 hours apart.
Change to: How Much: How Often / When:
Add: How Much: How Often / When:
Other Treatments
/
Care: (i.e.: sleep, devices):
SEIZURE ACTION PLAN FOR
(INSERT NAME HERE)
Attach Student
Photo
DANGER – GET HELP NOW
Follow Seizure First Aid Below
Find adult trained on rescue medication:
Name: Number:
Record Duration and time of each seizure(s)
Call 911 if:
When EMS arrives, a medical provider will perform an individual assessment to determine appropriate next steps.
Rescue Therapy:
Rescue therapy provided according to physician’s order:
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
POST SEIZURE RECOVERY
Typical Behaviors / Needs After Seizure:
Headache Drowsiness / Sleep Nausea Aggression
Confusion / Wandering
Blank Staring
Other Specify:
Reviewed / Approved by:
______________________________________________________________________________________________________________________________________
Physician Signature Date
______________________________________________________________________________________________________________________________________
Parent / Guardian Signature Date
SEIZURE FIRST AID
LEARN MORE AND GET A DOWNLOADABLE VERSION OF THIS ACTION PLAN AT:
SEIZURE
ACTION PLAN
• Child has a convulsive seizures lasting more than minutes
• Child has repeated seizures without regaining consciousness
• Child is injured or has diabetes
• Child is having breathing difficulty
childneurologyfoundation.org/sudep epilepsy.com/sudep-institutedannydid.org
Observe and Record What Happens
Stay Calm
Don’t Hold Down
Cushion Head, Remove Glasses
As Seizure Ends, Offer Help
Don’t Put Anything in the
Person’s Mouth, Turn on Their Side
Loosen Tight Clothing
Image adapted with permission from the Epilepsy Foundation of America
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When rescue therapy may be needed:
WHEN AND WHAT TO DO
If seizure (cluster, # or length) ________________________________________________________________________
Name of Med/Rx ________________________________ How much to give (dose) ________________________
How to give _____________________________________________________________________________________
If seizure (cluster, # or length) ________________________________________________________________________
Name of Med/Rx ________________________________ How much to give (dose) ________________________
How to give _____________________________________________________________________________________
If seizure (cluster, # or length) ________________________________________________________________________
Name of Med/Rx ________________________________ How much to give (dose) ________________________
How to give _____________________________________________________________________________________
Name:
———————————————————————————————————————————————————
Birth Date:
———————————————————
Address:
——————————————————————————————————————————————————
Phone:
—————————————————————
Emergency Contact/Relationship
————————————————————————————————————
Phone:
—————————————————————
SEIZURE ACTION PLAN (SAP)
How to respond to a seizure (check all that apply)
F
First aid – Stay. Safe. Side.
F
Notify emergency contact at ______________________________
F
Give rescue therapy according to SAP
F
Call 911 for transport to __________________________________________
F
Notify emergency contact
F
Other ________________________________________________
Seizure Type How Long It Lasts How Often What Happens
First aid for any seizure
F
STAY calm, keep calm, begin timing seizure
F
Keep me SAFE – remove harmful objects,
don’t restrain, protect head
F
SIDE – turn on side if not awake, keep airway clear,
don’t put objects in mouth
F
STAY until recovered from seizure
F
Swipe magnet for VNS
F
Write down what happens _____________________
F
Other _____________________________________
When to call 911
F
Seizure with loss of consciousness longer than 5 minutes,
not responding to rescue med if available
F
Repeated seizures longer than 10 minutes, no recovery between
them, not responding to rescue med if available
F
Diculty breathing after seizure
F
Serious injury occurs or suspected, seizure in water
When to call your provider first
F
Change in seizure type, number or pattern
F
Person does not return to usual behavior (i.e., confused for a
long period)
F
First time seizure that stops on its’ own
F
Other medical problems or pregnancy need to be checked
Seizure Information
Seizure Action Plan continued
Care after seizure
What type of help is needed? (describe) _______________________________________________________________
When is person able to resume usual activity? ___________________________________________________________
Health care contacts
Epilepsy Provider:
——————————————————————————————————————
Phone:
———————————————————————————
Primary Care:
————————————————————————————————————————
Phone:
———————————————————————————
Preferred Hospital:
—————————————————————————————————————
Phone:
———————————————————————————
Pharmacy:
——————————————————————————————————————————
Phone:
———————————————————————————
My signature
————————————————————————————————————————————————————
Date
—————————————————
Provider signature
—————————————————————————————————————————————————
Date
—————————————————
Epilepsy.com
©2020 Epilepsy Foundation of America, Inc.
Revised 01/2020 130SRP/PAB1216
Triggers: _________________________________________________________________________________________________
Important Medical History _______________________________________________________________________________________________________
Allergies _______________________________________________________________________________________________________________________
Epilepsy Surgery (type, date, side eects) ________________________________________________________________________
Device: VNS RNS DBS Date Implanted _______________________________________________________________
Diet Therapy Ketogenic Low Glycemic Modified Atkins Other (describe) ____________________________________
Special Instructions:
_________________________________________________________________________________________
_______________________________________________________________________________________________
Medicine Name Total Daily Amount
Amount of
Tab/Liquid
How Taken
(time of each dose and how much)
Daily seizure medicine
Other information
Special instructions
First Responders: _________________________________________________________________________________
_______________________________________________________________________________________________
Emergency Department: ___________________________________________________________________________
_______________________________________________________________________________________________
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SEIZURE ACTION PLAN FOR (INSERT NAME HERE)

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Completed 24 May 2022

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