Student ______DOB___/___/___
School______Grade______
Teacher/Homeroom______School Year 20___-20___

Bloomington Schools Health Services

1350 West 106th Street

Bloomington, MN 55431-4126

SEIZURE DISORDER EMERGENCY HEALTH PLAN

CONTACTS:

Parent/Guardian______H#______W#______Cell/Pager#______

Parent/Guardian______H#______W#______Cell/Pager#______

Physician/Clinic______Phone#______

Hospital of choice______

Medications Home School

Name______Dose ______Time ______

Name ______Dose ______Time ______

Name: ______Dose ______Time ______

ALLERGIES_______

SEIZURE INFORMATION

  1. Last observed seizure (month and year):______
  1. Number of seizures in the past year: ______
  1. Warning signs: ______
  1. Length of typical seizure: ______
  1. Parts of body involved: ______

TYPES OF LIMITATIONS:

  • Playground equipment____ yes ____ no____ N/A
  • Swimming____ yes____ no____N/A
  • Machinery operation____yes____ no____N/A
  • Other: ______

FIELD TRIP PLAN:______

______

First Aid for Seizures:
  1. call the Health Associate at ext.______
  2. Gently protect the student from injury. Help him/her to a lying position, preferably on side. Place something soft under head, loosen tight clothing and clear the area of hard or sharp objects.
  3. Stay with the student until full recovery has occurred. Allow the student to rest if he/she needs it.
  4. Be reassuring and supportive when consciousness returns.
  5. Complete Seizure Activity Log

EMERGENCY PLAN OF CARE:

  1. Call 911 and parent if:
  • Seizure is longer than _____ minutes
  • Student has one seizure after another
  • Student is having difficulty breathing

*DO NOT: FORCE ANY OBJECTS INTO THE STUDENT’S MOUTH

RESTRAIN MOVEMENTS

OFFER FOOD OR LIQUIDS UNTIL FULLY AWAKE

*I give health office personnel permission to consult (both verbally and in writing) with the above named student’s physician regarding any questions that arise about the medical condition and/or medication/treatments/procedures being used to treat the condition.

*It is recommended that the parent/guardian complete a transportation form from the bus company.

Parent/Guardian:______Date: ______

*Physician:______Phone:______Date:______

*Only required if this form is used as a doctor’s order for medication(s) or treatment(s)

Health Service Personnel :______Date:______

  • We ask you to complete this form at the beginning of every school year to ensure that we have the most current information on your child.
  • The school district intends to use the requested information to provide for your child’s health and safety while at school.
  • You may refuse to supply the requested personal information. There will be no consequence for not providing the information. It may result in an incomplete health plan for your child.
  • The information you provide will be shared only with staff in the school district whose jobs require access to this information to ensure your child’s safety.
  • If we are unable to reach you or your designee during an emergency, we will call 911 for assistance if needed.
  • I give permission for the school health service staff to consult with my child’s physician about any questions regarding the listed medication(s) or medical condition(s) being treated.
  • Please contact your school promptly with any changes of information on this form.

HS #53 5/05