Questionnaire For Parent Of A Student With Seizures
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2questionnaire 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
student’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 Name: ______________________ Tel. (H):______________(W):_________________(C): _____________
Other Emergency Contact: ____________________ Tel. (H):______________(W):_________________(C): _____________
Child’s Neurologist: __________________________ Tel:__________________Location: _____________________________
Child’s Primary Care Dr.: ______________________ Tel:__________________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 Seizure First Aid
basic first aid: care and comfort measures
Stay calm & track time
Keep child safe
9.
What basic first aid procedures should be taken when your child has a
Do not restrain
seizure in school? ______________________________________________
Do not put anything in mouth
_____________________________________________________________
Stay with child until fully conscious
_____________________________________________________________
record seizure in log
For tonic-clonic (grand mal) seizure:
_____________________________________________________________
Protect head
_____________________________________________________________
Keep airway open/watch breathing
Turn child on side
10. Will your child need to leave the classroom after a seizure?
YES
NO
if YES, What process would you recommend for returning your child to the classroom?: ____________________
______________________________________________________________________________________________________
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