Seizure Disorder Health Care Plan And Medication Administration Authorization Form
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PRINCE GEORGE COUNTY PUBLIC SCHOOLS
Seizure Disorder Health Care Plan and Medication Administration Authorization
Student’s Name: ________________________________________ DOB: ________________ School: ________________________
Medication Allergies: __________________________________________________________ School Year: ____________________
♥ TO BE COMPLETED BY PHYSICIAN OR LICENSED PRESCRIBER ♥
Seizure Type(s): ________________________________________ Aura/Type: ____________________________________________
Frequency: ____________________________________________ Duration: ______________________________________________
List any special considerations, equipment, activity restrictions, treatments or special diet required at school related to seizure disorder:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Medication(s) given at home: _____________________________________________________________________________________
MEDICATION(S) TO BE ADMINISTERED DURING SCHOOL HOURS BY SCHOOL PERSONNEL FOR CONTROL OF SEIZURES:
Prescription
: Medication:______________________________________________________________________________________
Dosage, Time, Route:_______________________________________________________________________________
Duration:__________________________________________ Date of Prescription:______________________________
Possible Side Effects:_______________________________________________________________________________
Prescription:
Medication:______________________________________________________________________________________
Dosage, Time, Route:_______________________________________________________________________________
Duration:__________________________________________ Date of Prescription:______________________________
Possible Side Effects: _______________________________________________________________________________
Signs of seizure activity may include: staring/visual disturbance, unusual smell/tastes, stiffening of arms and legs followed by
rhythmic jerking with or without unresponsiveness, shallow breathing, drooling, bluish skin, and loss of bladder or bowel control.
If seizure activity occurs, provide the following measures:
Remain calm. No one can stop a seizure once it starts.
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An adult should remain with the student. Provide privacy.
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Protect student’s head from injury by placing folded blanket, towel or jacket under head.
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Assist student to lie down on his/her side to keep airway clear.
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Loosen collar if needed.
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Do not attempt to hold down or restrain student’s movements. (This may cause fractures or bruising)
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Do not place objects, food, drink or medication in mouth. (This may cause aspiration, vomiting, broken teeth, bitten tongue)
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Do not move student if injury has occurred.
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Administer medication as prescribed above.
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Document seizure activity to include: date, time seizure began, area of body where seizure began, loss of bladder or bowel
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control, and type of movement of head, face or arms.
Notify principal and parent/guardian. (Refer to bottom of page 2 for emergency contact phone numbers)
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CALL 911 for ANY of the following:
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Seizure lasts more than 5 minutes.
Two or more consecutive seizures occur.
More seizures than usual or change in type of seizure.
Student stops breathing or does not have a pulse. (Perform CPR if required)
Student is diabetic or pregnant.
There is evidence of injury or seizure occurs in water.
Student cannot be awakened, pupils are not equal in size and/or vomits continuously after seizure has ended.
Other: ________________________________________________________________________________________________
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After a seizure is over, monitor student’s breathing and allow rest for at least 30 minutes. Orient student to surroundings.
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE MY CHILD TO MEDICAL FACILITY!
Parent/Guardian Signature _______________________________________________________________________ Date __________________________________
Physician/Prescriber Signature ____________________________________________________________________ Date __________________________________
Physician/Prescriber PRINTED Name_________________________________________ Phone__________________________ FAX_________________________
HSM 0005-0809
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