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Seizure Action Plan

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