Student Seizure Disorder Health Care Plan Template (Page 2 of 2) in pdf

The Parent/Guardian should complete the following:

Physician Name: ____________________________________Date last seen for this condition: ________________

Does your child have any allergies (list as specific food, medication, insect sting, etc.): ______________________

_____________________________________________________________________________________________

How many times has your child been seen in the emergency room for this condition in the last year? ____________

Age of onset of Seizures: _________Date of last Seizure: _______________Time/length of Seizure: ___________

Please list known triggers for seizure activity: ________________________________________________________

_____________________________________________________________________________________________

Please list any warning signs and/or a behavioral change that may indicate a seizure is about to occur: ___________

_____________________________________________________________________________________________

Please list any medication taken at home for seizure management:

Name

Dosage

Time/Frequency

Route Administered

**Any medication needed by student at school will require that a Medication Authorization Form be

completed and signed by a physician and parent/guardian.

Parent/Guardian Consent: I have reviewed and approve this health care and emergency plan for my child. I

authorize school board employees to give medication to my child as prescribed by physician and to provide

emergency treatment to my child as specified in the above plan. I understand that I am responsible for supplying

any medication, supplies or equipment needed by my child to manage his/her seizure disorder at school. I authorize

the school to contact my child’s physician or designee regarding my child’s health condition. This health care plan

can be updated at any time my child’s circumstances require modifications in treatment, but will be reviewed

annually. I agree to notify the school if a change occurs in my child’s health plan. I also consent to the release of

the information contained in this care plan to Pulaski County School personnel who care for my child and who may

need to know this information to maintain my child’s health and safety.

Parent/Guardian Signature: ________________________________________________Date: __________________

School Nurse Signature: __________________________________________________Date: __________________

Student Seizure Disorder Health Care Plan Template Page 2