Eastern Oregon Head Start

Seizure Health Care Plan

(Parent and Health Care Provider complete this form together)

Child’s Name:______DOB______/______/______

Parent/Guardian Name:______Phone______

Allergies:______

Insurance:______

Health Care Provider:______Phone______

Seizure Specialist:______Phone______

Emergency Contacts

Emergency Contact______Phone______

Seizure Disorder:

Type:______Date Diagnosed:___/___/____

Description: (What should staff be alerted to?)

Response: (How should staff respond?)

Current Medications:
Medication(s) Name Dosage Amount Prescribed times to give Dosage Frequency
(How far apart to be given)
1.
2.
3.

Seizure Care Plan continued

Child’s Name______

Will medication be stored at Head Start center? oyes ono

Location of Medication in Center______

Will medication be administered at Head Start center by staff? oyes ono

Completed Medication Authorization Form is required prior to medication administration.

Field Trips:

Does medication need to accompany child on field trip? oyes ono

Steps to take during a seizure:

Þ Call 911 if seizure lasts longer than ______or child becomes blue or stops breathing.

Þ Stay calm

Þ Position child on side

Þ Clear area around child of hazards

Þ Do not put anything in child’s mouth

Þ Notify parent/guardian

Þ Call Health manager after care is complete (962-3798 Head Start Health Manager)

Þ Other:______

Parent Directives:

Comments: / Disaster Supplies:
o Medication for 3 days
o Out-of-town contacts

Training Needs:

Is specialized training necessary for classroom staff? oyes ono

______

Parent/Guardian Signature Date Parent/Guardian Signature Date

______

Staff Signature Date Diagnosing Health Care Provider’s Signature

Forms/Child Health and Development/Health/Seizure Health Care Plan Reviewed 2010