WINTER SPRING 2012SEIZURE NFORMATIONEIZURE INFORMATION WINTER/SPRING 2012


IF YOUR CHILD HAS SEIZURES, this form MUST be completed and verifi ed by a signature before the participant is allowed to join any NWSRA program. Please check the correct response, complete each category and list any other information you feel NWSRA should be aware of to provide safe and enjoyable activities for the individual being registered.


CONTACT INFORMATION:


Participant Name: ______________________________________________________________________ Date of Birth:____________________ Parent/Guardian Name: ______________________________________________ Tel.(H) _____________ (W) _____________(C) ___________ Other Emergency Contact: ___________________________________________ Tel.(H) _____________ (W) _____________(C) ___________ Participant Primary Care Dr.: _____________________________________________________________ Tel: ____________________________ SEIZURE INFORMATION: 1. When was the participant diagnosed with seizures or epilepsy? _______________________________________________________________ Seizure Type


Length Frequency


Absence (staring spell) Simple Partial Complex Partial Atonic (drop)


Generalized (Gran Mal) Other (explain):


2. What might trigger a seizure in the participant? ___________________________________________________________________________ 3. Are there any warnings and or behavior changes before the seizure occurs? Yes___ No___ If yes, please explain: ______________________ 4. When was the participant's last seizure? _________________________________________________________________________________ 5. Has there been any recent change in the participant's seizure patterns? Yes___ No___ If yes, please explain: __________________________ 6. How does the participant react after a seizure is over? ______________________________________________________________________ 7. How do other illnesses affect the participant's seizure control? _______________________________________________________________ BASIC FIRST AID: Care and Comfort Measures 8. What basic fi rst aid procedures should be taken when the participant has a seizure? _______________________________________________ _________________________________________________________________________________________________________________ SEIZURE EMERGENCIES: 9. Please describe what constitutes an emergency for the participant? ____________________________________________________________ 10. Has the participant ever been hospitalized for continuous seizures? Yes ___ No ___ If yes, please explain: ___________________________ A seizure is generally considered an emergency when: A convulsive (tonic-clonic) seizure lasts longer than 5 minutes • Repeated seizures without regaining consciousness • A fi rst time seizure • Participant is injured or diabetic • Participant has breathing diffi culties • Participant has a seizure in water. SEIZURE MEDICATION AND TREATMENT INFORMATION: 11. What medication(s) for seizures does the participant take? Medication


Date Started Dosage Frequency and time of day taken Possible side effects Description


12. What emergency/rescue seizure medications are prescribed for the participant? Medication


Dosage


Administration Instructions (timing* & method**)


What to do after administration:


*After 2nd or 3rd seizure, for cluster of seizure, etc. **Orally, under tongue, rectally, etc. NWSRA DOES NOT ADMINISTER RECTAL VALIUM. 13. Does your child have a Vagal Nerve Stimulator Yes ___ No ___ If yes, please describe instructions for appropriate magnet use: __________ _________________________________________________________________________________________________________________


GENERAL COMMUNICATION ISSUES: 14. What is the best way for us to communicate with you about the participant's seizure(s)? ___________________________________________ 15. Is there any other information that NWSRA should know? __________________________________________________________________ Parent/Guardian Signature: ______________________________________________________________________ Date: ___________________ Dates Updated:________,________


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