Seizure Activity Information Form
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Email *
Child's name *
Child's Date of Birth *
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When was your child diagnosed with seizures?
Are there any triggers for the Seizure Activity? *
If yes for triggers, what are the triggers for your child?
What type of seizures does your child have? *
Is the child conscious or unconscious during the seizure? *
Does the child urinate or have a bowel movement with the seizure? *
How long does the seizure usually last?
Has your child had more than one seizure? *
Are there any symptoms for your child after the seizure? *
If the child has symptoms after the seizure, please list below
Does your child see a Neurologist? *
Neurologist Name and contact information:
When was the child's last seizure? *
Will your child need to leave the classroom after a seizure? *
If yes, what process would you recommend for returning to the classroom?
Has the child ever been hospitalized for seizures? *
If yes, when was the child hospitalized?
Check all that apply and describe any considerations or precautions that should be taken
Check all that Apply
Physical Function
Learning
Behavior
Mood/Coping
Physical Educations/Gym/Sports
Recess
Field Trips
There are no special needs for child
What is the best way for us to communicate with you about your child's seizures? *
Do you have any questions for the Nurse? *
Parent/Guardian name *
Parent/Guardian telephone number *
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