Download/Print Copy of Seizure Action Plan
Seizure Action Plan
Download/Print Copy of Seizure Action Plan
- Name
- Birth Date
- Address
- Phone
- Emergency Contact/Relationship
- Phone
Seizure Information
- Seizure Type
- How long it lasts
- How often
- What happens
How to respond to a Seizure (check all that apply)
- First Aid - Stay. Safe. Side
- Give rescue therapy according to SAP
- Notify Emergency Contact
- Notify emergency contact at:
- Call 911 for transport to:
- Other:
First aid for any seizure
- STAY calm, keep calm, begin timing seizure
- Keep me SAFE – remove harmful objects, don’t restrain, protect head
- SIDE – turn on side if not awake, keep airway clear, don’t put objects in mouth
- STAY until recovered from seizure
- Swipe magnet for VNS
- Write down what happens
- Other
When to call 911
- Seizure with loss of consciousness longer than 5 minutes, not responding to rescue med if available
- Repeated seizures longer than 10 minutes, no recovery between them, not responding to rescue med if available
- Difficulty breathing after seizure
- Serious injury occurs or suspected, seizure in water
When to call your provider first
- Change in seizure type, number or pattern
- Person does not return to usual behavior (i.e., confused for a long period)
- First time seizure that stops on its’ own
- Other medical problems or pregnancy need to be checked
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
Care after seizure
- What type of help is needed? (describe)
- When is person able to resume usual activity?
Special instructions
- First Responders:
- Emergency Department:
Daily seizure medicine
- Medicine Name
- Total Daily
- Amount Amount of Tab/Liquid
- How Taken (time of each dose and how much)
Other Information
- Triggers:
- Important Medical History
- Allergies
- Epilepsy Surgery (type, date, side effects)
- Device:
- VNS
- RNS
- DBS
- Date Implanted
- Diet Therapy
- Ketogenic
- Low Glycemic
- Modified Atkins
- Other (describe)
- Special Instructions:
Health care contacts
- Epilepsy Provider:
- Phone
- Primary Care:
- Phone
- Preferred Hospital
- Phone
- Pharmacy
- Phone
- My signature
- Date
- Provider signature
- Date