Seizure Questionnaire

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Upon enrolling, you selected that your child has seizures. Please fill this form out to better help me update our records and care for your child while they are on campus. Ashley Zottarelli, Tobias school nurse

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Seizure type *

Seizure length *

Seizure frequency *

Description of seizures *

Any recent changes to seizures? *

Triggers/warning signs of seizures *

Student's response after a seizure *

Does your student need to leave the classroom for a seizure? *

Yes

Unsure

Mục khác:

If the above answer was yes, please describe process of returning to class or if they need to be sent home *

Does your child have emergency medication? *

Yes

Mục khác:

If yes, please describe the medication and directed use *

Does your child take daily, scheduled medication for seizures? *

Yes

Mục khác:

If yes, what are the medications that are scheduled and when are they given? *

Does your child have a Vagal Nerve Stimulator? *

Yes

Please describe any special considerations or precautions needed during school activities, field trips, sports, ect.) *

Best way to contact you in an emergency, please provide all numbers/ways *

Gửi

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