Seizure Monitoring Chart
ADVERTISEMENT
1
2Seizure Monitoring Chart
Page 1 of 2
Student: _________________________________ Date of Birth: _________________
School: __________________________________ School Year: _________________
Type of Seizure: ___ Grand Mal (Tonic-clonic)
___ Petit Mal (Absence)
Other (Specify): _________________________________________________________
Please specify likely characteristics.
Recommended
Interventions /
Comments
Duration
Specify seconds, minutes, etc.
Aura
Is there an Aura?
Yes / No
Conditions or behaviors that usually precede the
seizures
Extremities
Limp
Flexed
Extended
Jerking
Rt. Arm
Lt. Arm
Rt. Leg
Lt. Leg
Eyes
Rolled Back
Yes
No
Staring Straight Ahead
Yes
No
Twitching Back and Forth
Yes
No
Looking to Right
Yes
No
Looking to Left
Yes
No
Mouth
Drawn to Right
Yes
No
Drawn to Left
Yes
No
Bites Tongue/Cheek
Yes
No
Teeth Clenched
Yes
No
Breathing
Noisy Breathing
Yes
No
Heavy Breathing
Yes
No
Shallow Breathing
Yes
No
Other
Change in skin color
Yes
No
Drooling
Yes
No
Incontinent-Urine
Yes
No
Incontinent-Stool
Yes
No
Vomiting
Yes
No
If symptoms persist after primary care
If breathing stops:
• Call 911
provider recommendations have been
• CPR certified school personnel should
followed:
• Notify parent/guardian
initiate rescue breathing (and CPS if
• Call 911
necessary)
• Notify parent/guardian
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life