Questionnaire for Parent of a Student with Seizures
Please complete all questions. This information is essential for the school nurse and school staff in determining your child’s special
needs and providing a positive and supportive learning environment. If you have any questions about how to complete this form,
please contact your child’s school nurse.
Contact Information
Student’s Name
School Year
Date of Birth
School
Grade
Classroom
Parent/Guardian
Phone
Work
Cell
Parent/Guardian Email
Other Emergency Contact
Phone
Work
Cell
Child’s Neurologist
Phone
Location
Child’s Primary Care Doctor
Phone
Location
Significant Medical History or Conditions
Seizure Information
1. When was your child diagnosed with seizures or epilepsy? _________________________________________________________
2. Seizure type(s)
Seizure Type
Length
Frequency
Description
3. What might trigger a seizure in your child? _____________________________________________________________________
❒
❒
4. Are there any warnings and/or behavior changes before the seizure occurs?
YES
NO
If YES, please explain: _____________________________________________________________________________________
5. When was your child’s last seizure? ___________________________________________________________________________
❒
❒
6. Has there been any recent change in your child’s seizure patterns?
YES
NO
If YES, please explain: _____________________________________________________________________________________
7. How does your child react after a seizure is over? ________________________________________________________________
8. How do other illnesses affect your child’s seizure control? __________________________________________________________
Basic First Aid: Care & Comfort
Basic Seizure First Aid
9. What basic first aid procedures should be taken when your child has a seizure in
•
Stay calm & track time
school?
•
Keep child safe
•
Do not restrain
•
Do not put anything in mouth
•
Stay with child until fully conscious
•
Record seizure in log
For tonic-clonic seizure:
❒
❒
10. Will your child need to leave the classroom after a seizure?
YES
NO
•
Protect head
If YES, what process would you recommend for returning your child to classroom:
•
Keep airway open/watch breathing
•
Turn child on side