Epilepsy Action Plan

Youth Camp

Epilepsy Action Plan

This form can be completed by parent or doctor

First Name

Last Name

Date form filled out

1. What type of Epilepsy does your child have?

2. What are your childs usual symptoms when he/she has an epileptic seizure?

3. Does your child require epilepsy medication everyday?

Medication #1

Method Used

How Much

When

Medication #2

Method Used

How Much

When

4. Does your child need ASSISTANCE from staff to take epilepsy medication?

5. If your child has an epileptic seizure what procedure do you wish staff to follow?

6. Any other relevant information?

PLEASE SIGN

Please contact me if my child has an epileptic seizure and the above treatment does not prevent hospitalisation OR if he/she requires emergency treatment.

Name in full

Date