Adult Seizure Action Plan

Adult Seizure Action Plan
ADULT Seizure Action Plan & Patient Questionnaire

THIS INDIVIDUAL IS BEING TREATED FOR A SEIZURE DISORDER. INFORMATION BELOW SHOULD ASSIST YOU IF A SEIZURE OCCURS.
Name
Date of Birth

MonthDayYear
Date
Emergency Contact's Name
Emergency Contact's Cell Phone #
Treating Physician
Physician's Phone #
Format: (000) 000-0000.
Significant medical history
Seizure Type, Average Length, & Average Frequency
Seizure triggers or warning signs
Post seizure behavior
Please describe basic first aid procedures
A seizure emergency for this person is defined as
Seizure Emergency Protocol (Check All That Apply)

Call 911 for Transport to Nearest HospitalNotify Parent or Emergency ContactNotify DoctorAdminister Emergency Medication(s)Other
Emergency Medication, Dosage, Route, Other Information
Does this person have a Vagus Nerve Stimulator?

YesNo
If YES describe magnet protocol
Special Considerations & Safety Precautions (regarding acitvities, travel, community outings, etc)
Individual Signature
Date

MonthDayYear
Date
ParentGuardian Signature if minor
Date

MonthDayYear
Date
Should be Empty: