Epilepsy Management and Emergency Action Plan

Patient Information

• Name: _________________________
• Date of Birth: _________________
• Emergency Contact: _____________
• Phone: ________________________

Seizure Information

Type(s) of Seizures

• Primary seizure type: ___________
• Typical duration: _______________
• Frequency: ____________________

Known Triggers

• Lack of sleep
• Missed medications
• Stress
• Flashing lights
• Other: _____________________

Current Medications

Emergency Protocol

When to Administer Emergency Medication

• If seizure lasts longer than ____ minutes
• If ____ or more seizures occur within ____ hours

Emergency Medication Instructions

1. Medication name: ________________
2. Dose: _________________________
3. Administration route: ____________

When to Call 911

• Seizure lasting > 5 minutes
• Difficulty breathing
• Injury during seizure
• Seizures occurring in water
• First-time seizure

Daily Management

Safety Precautions

• Wear medical ID
• Avoid swimming alone
• Take medications as prescribed
• Maintain regular sleep schedule

Activity Restrictions

• Driving: ______________________
• Sports: ______________________
• Other: ______________________

Healthcare Provider Information

• Neurologist: __________________
• Phone: _______________________
• Primary Care: _________________
• Phone: _______________________

Follow-up Care

• Next appointment: _____________
• Tests needed: ________________

Plan reviewed by: _____________ Date: _______

Healthcare Provider Signature: ____________