Name:

Last Name

DOB: Teacher:

First Name

Gender: M

F

Middle Name

Grade:

School Year:

CIF: Room #:

Seizure Disorder Questionnaire Please complete and return to the School Nurse. The following information is helpful in determining any special needs. Person to Contact:

Phone (Work/Home/Cell): Phone (Work/Home/Cell):

Relationship:

1.

(

)

(

)

2.

(

)

(

)

3.

(

)

(

)

4.

(

)

(

)

Health Care Provider:

Clinic:

Phone:

( Neurologist:

)

Clinic:

Phone:

( Hospital:

)

Address:

Phone:

(

Age at diagnosis of seizure disorder:

)

Does this student wear a medical alert bracelet/necklace? Yes No

Please check the type(s) of seizures this student has had: Tonic-Clonic (Grand Mal)

Simple (Jacksonian/Focal Motor)

Complex (Psychomotor/Temporal Lobe)

Absence (Petit Mal)

Febrile (with high fever)

Other (please specify):

When was this student’s most recent seizure? How often does this student typically experience seizures? Daily Weekly Monthly Other: How long does a typical seizure last? Seconds Minutes Other: Has this student ever been treated for Status Epilepticus (a prolonged seizure)? Yes

No

Does this student usually experience any early warning signs/symptoms before a seizure (i.e. sensory or mental aura)? Yes No

If Yes, please describe:

Does this student recognize these signs/symptoms? Yes

No

Please check this student’s usual signs/symptoms of a seizure: Loss of Consciousness Aimless Wandering Falling Down Fluttering Eyelids Muscle Stiffness Blank Stare Rhythmic Convulsions Confusion Purposeless Activity Repetitive Acts/Movements

Twitch ing/Jerking of Body Part Loss of Awareness (i.e. unresponsive) Loss of Control (i.e. bladder, bowel, drooling) Other:

Please check any known triggers for this student’s seizures: Bright Lights/Strobe

Stress

Fever

Temperature Changes

Loud Noises

Other:

Fatigue

Hunger

Complete reverse side

H-88 11-13-08

Please describe how this student acts after a seizure (i.e. drowsy, sleepy, headache, etc.):

Please list any activities that this student should avoid:

Please list any specific activities in which this student needs particularly close supervision:

Medication(s) taken on a regular basis: Name: By (mouth, injection, etc.):

Dose:

Time of Day:

Emergency medication(s): Name:

Dose:

Time of Day:

By (mouth, injection, etc.):

Please list any side effects of this student’s medications that may affect the student’s learning and/or behavior:

•

If a medication is to be given at school, a medication authorization form must be completed yearly. A prescribing health professional may authorize self-administration of medication if the student is deemed capable. The medication must be in the original labeled container. (When you get the prescription filled, please ask the pharmacist to put it into two containers so the student will have one for school and one for home use.)

•

In an acute emergency, the student will be transported by paramedics to the hospital. Transportation in a non-acute situation is the responsibility of the parent/guardian(s). Any charges incurred are the responsibility of the parent/ guardian(s).

Has this student received education related to seizures: By health care provider

At camp

At support group

Other:

Please add anything else that you would like school personnel to know about this student’s seizures (or related health conditions):

Information provided by:

Signature

Relationship

Date

I authorize reciprocal release of information related to seizure disorder between the school nurse and the health care provider. Parent/Guardian Signature H-88

Date 11-13-08