EMERGENCY ACTION PLAN Student Name [PDF]

Grade: ______. DOB: ______ Sex: ______ ... _____ Generalized (Tonic-Clonic). ______ Partial (Local). _____ Complex (Psyc

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Idea Transcript


***PRIOR LAKE-SAVAGE ARE SCHOOLS HEALTH SERVICES***

SEIZURE HISTORY / IHP / EMERGENCY ACTION PLAN Student Name: _____________________________________ Grade: ________ DOB: ____________ Sex: _______ Room Number: ______ MedicAlert ID? Y N Parent / Guardian Name: ____________________________________________ Phone: (H) _______________ (W) ______________ (CELL) _______________ Parent / Guardian Name: ____________________________________________ Phone: (H) _______________ (W) ______________ (CELL) _______________ Physician Name: ____________________________ Phone: ________________ Neurologist: ________________________________ Clinic: ________________ Hospital (In Case of Emergency): _____________________________________ Type(s) of Seizure Disorder _____ Generalized (Tonic-Clonic) ______ Partial (Local) _____ Complex (Psychomotor) ______ Absence (Petit Mal) _____ Other ______________________________________________________ Date of last seizure: ___________________ Does your student have a aura (warning sign) before the seizure? ___Yes ___No Describe the aura: Describe a typical seizure, including triggers and behavior after seizure: Usual duration: Frequency of seizures and likelihood of having one at school: Seizure History: Age at diagnosis: ______________________ Has your student ever been hospitalized or seizures? ___Yes ___No Date of last hospitalization for seizure: _________________________________ Has your student had an EEG? ___ Yes ___No Results of EEG:

Date:______________

Current Treatment: Medications (state name, dose and times given): *med form required if needed at school Side effects of medication: Length of time on current medications:

Please list any needed classroom/Phy Ed restrictions needed for ______________

First Aid and Immediate Treatment (for tonic-clonic seizure): Help student lie down and cushion head Remove glasses Loosen tight clothing Clear area of sharp or hard objects Turn student to side to prevent aspiration Monitor length of seizure and record (on flow sheet, if avail.) Don’t put anything in student’s mouth Don’t attempt to give student anything to drink If out in sun, try to shade student’s head Notify parent/guardian Emergency Plan: 9-1-1 will be called if: Seizure lasts longer than 5 minutes Student is having difficulty breathing Vomitus is aspirated A significant injury occurs during the seizure Seizure reoccurs Other: Parent requests or cannot be located. st What would you like school staff to do (other than routine 1 aid) if your child has a seizure at school?

Call parent when:

Parent signature_______________________________

Date_________________

Physician signature _____________________________

Date _________________

(not required)

Reviewed by LSN ______________________________

Revised 04/05

Date _________________

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