Personal Epilepsy Emergency Action Plan

Patient Information

Name: _________________________ Date of Birth: _________________ Emergency Contacts: ____________

Seizure Information

My Typical Seizure Types

• Type 1: ____________________
• Type 2: ____________________
• Duration: __________________

Regular Medications

1. Name: ____________ Dose: ______ Time: ______
2. Name: ____________ Dose: ______ Time: ______
3. Name: ____________ Dose: ______ Time: ______

Emergency Response Protocol

When to Administer Rescue Medication

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

Rescue Medication Instructions

Medication: ___________________ Dose: ________________________ Route: _______________________

When to Call 911

• If seizure lasts longer than 5 minutes
• If breathing difficulty occurs
• If injury occurs during seizure
• If seizure occurs in water
• If patient doesn't return to baseline within ____ minutes

First Aid Steps

1. Time the seizure
2. Keep person safe and remove harmful objects
3. Turn person on their side
4. Do not put anything in mouth
5. Stay with person until fully awake

Important Medical Information

• Known triggers: ________________
• Allergies: ____________________
• Other medical conditions: _______

Healthcare Provider Information

Neurologist: ___________________ Phone: ________________________ Primary Care: __________________ Phone: ________________________

_Last Updated: _________________