Fillable SEIZURE ACTION PLAN (SAP) (Epilepsy Foundation)

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SEIZURE ACTION PLAN (SAP) (Epilepsy Foundation)

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  • 13 check-boxes
  • 81 other fields

Country of origin: US
File type: PDF

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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:
—————————————————————
Parent/Guardian:
—————————————————————————————————————————————
Phone:
—————————————————————
Emergency Contact/Relationship
————————————————————————————————————
Phone:
—————————————————————
SEIZURE ACTION PLAN (SAP)
Protocol for seizure during school (check all that apply)
F
First aid – Stay. Safe. Side.
F
Contact school nurse at __________________________________
F
Give rescue therapy according to SAP
F
Call 911 for transport to __________________________________________
F
Notify parent/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 _____________________________________
Seizure Information
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 Action Plan continued
Care after seizure
What type of help is needed? (describe) _______________________________________________________________
When is student 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 (SAP) (Epilepsy Foundation)

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Completed 31 July 2021

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