1. SEIZURE RECORD


      Everett Public Schools

      Health Services


       


       





      SEIZURE RECORD


       

      STUDENT’S NAME                DATE      

       

      CLASSROOM             TIME OF OCCURRENCE      

       

      PRECEDING CONDITIONS:

                                   

         Student’s Location            Student’s Activity

       

      Warning Signs No     Yes     If “Yes” describe              

                                   

      SEIZURE BEHAVIOR:

      Duration (if approximate, state it)                        

      Did student’s body stiffen?                No    Yes    

      Did student’s body shake?                  No    Yes    

      Parts of body involved                          

      Did student fall?                    No    Yes    

      Any apparent injury?                  No    Yes    

      Describe                                                          

      Did the student receive a bump or blow to the head? No ___________ Yes __________

      Describe:________________________________________________________________________________________________________________________________________________________________________________________________________________

      ****Consider consulting with student’s Health Care Provider on any Bump or Blow to the Head.

      Did student appear to become unaware of the environment?          No    Yes    

      Was there a change in color of the student’s lips, nail beds, etc?        No    Yes    

      Describe                                                                                        

      Did student wet or soil? - - - - - - - - - -- - - - - - - - - - - - - -  Urine        No    Yes    

                      Feces        No    Yes    

      Did student have difficulty breathing? - - - - - - - - - - - - - -  Before        No    Yes    

                   During        No    Yes    

                   After        No    Yes    

      Other                                                                                          

       

      Follow-up:

       

      Describe First Aid given:                                                        

      Describe student’s activity after seizure                                                                                  

      Original Copy to Parent/Guardian: [ ] Yes

      Reported by            

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      Seizure Record

      Effective: 7-01, 4/03, 5/04, 1/08