SEIZURE ACTION PLAN (SAP)
Name: ———————————————————————————————————————————————————— Birth Date:————————————————————
Address:——————————————————————————————————————————————————— Phone:——————————————————————
Emergency Contact/Relationship ————————————————————————————————————— Phone:——————————————————————

Seizure Information
Seizure Type

How Long It Lasts

How Often

What Happens

How to respond to a seizure (check all that apply)

FFirst aid – Stay. Safe. Side.

 Notify emergency contact at _______________________________F

Give rescue therapy according to SAP Call 911 for transport to ___________________________________________

F

Notify emergency contact

 Other_________________________________________________First aid for any seizure
FSTAY calm, keep calm, begin timing seizure

F

Keep me SAFE – remove harmful objects,
don’t restrain, protect headFSIDE – turn on side if not awake, keep airway clear,
don’t put objects in mouth

FSTAY until recovered from seizure

FSwipe magnet for VNS

F

Write down what happens ______________________F

Other ______________________________________

When to call 911

Seizure with loss of consciousness longer than 5 minutes,
not responding to rescue med if available
F Repeated seizures longer than 10 minutes, no recovery between
them, not responding to rescue med if available
F Difficulty breathing after seizure
F Serious injury occurs or suspected, seizure in waterF

When to call your provider first

Change in seizure type, number or pattern
Person does not return to usual behavior (i.e., confused for along period)
F First time seizure that stops on its’ own
F Other medical problems or pregnancy need to be checkedFF

When rescue therapy may be needed:
WHEN AND WHAT TO DO
If seizure (cluster, # or length)_________________________________________________________________________Name of Med/Rx _________________________________How much to give (dose) _________________________How to give______________________________________________________________________________________
If seizure (cluster, # or length)_________________________________________________________________________Name of Med/Rx _________________________________How much to give (dose) _________________________How to give______________________________________________________________________________________
If seizure (cluster, # or length)_________________________________________________________________________Name of Med/Rx _________________________________How much to give (dose) _________________________How to give______________________________________________________________________________________Seizure Action Plan continued

Care after seizure
What type of help is needed? (describe) ________________________________________________________________
When is person able to resume usual activity?____________________________________________________________

Special instructionsFirst Responders:_________________________________________________________________________________________________________________________________________________________________________________
Emergency Department: ___________________________________________________________________________________________________________________________________________________________________________

Daily seizure medicine
Medicine Name

Total Daily AmountAmount ofTab/LiquidHow Taken(time of each dose and how much)

Other information
Triggers: __________________________________________________________________________________________________
Important Medical History ________________________________________________________________________________________________________Allergies________________________________________________________________________________________________________________________
Epilepsy Surgery (type, date, side effects) _________________________________________________________________________
Device:  VNS

 RNS  DBS Date Implanted________________________________________________________________

Diet Therapy  Ketogenic

 Low Glycemic  Modified Atkins  Other (describe) ____________________________________

Special Instructions: _________________________________________________________________________________________________________________________________________________________________________________________

Health care contacts
Epilepsy Provider:——————————————————————————————————————— Phone:————————————————————————————
Primary Care:————————————————————————————————————————— Phone:————————————————————————————
Preferred Hospital:—————————————————————————————————————— Phone:————————————————————————————
Pharmacy:——————————————————————————————————————————— Phone:————————————————————————————
My signature————————————————————————————————————————————————————— Date——————————————————
Provider signature—————————————————————————————————————————————————— Date——————————————————

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Revised 01/2020
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