EPILEPSY Management Plan

<strong>EPILEPSY</strong><strong>Management</strong> <strong>Plan</strong>Date of Doctor’s Instructions: _______________Today’s Date: ________________Person’s Name: ____________________________ Gender: _____ Date of Birth: ________________EMERGENCY CONTACT PERSON(S)1. Name: ___________________________ Phone Home: ______________ Mobile/Work : ___________________2. Name: ___________________________ Phone Home: ______________ Mobile/Work : ___________________3. Name: ___________________________ Phone Home: ______________ Mobile/Work : ___________________Treating Doctor: ________________________________________ Phone ________________________<strong>EPILEPSY</strong> DIAGNOSIS & DETAILSType of seizure/s : ______________________________________________________________________Known Triggers : ____________________________________________________________________________________________________________________________________________________________Seizure Pattern: (What happens before, during and after) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________<strong>EPILEPSY</strong> MEDICATIONSName Dose Time GivenForm of Administratione.g Epilim 200mg 8am tablet___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________In the event of a seizure or seizures, I …………………………………………………authorise themanagement/staff/carers to follow the emergency action plan for ………………………………………. aspresented on the back of this document.Signed: __________________________________________Date: ___________________

<strong>EPILEPSY</strong>Action <strong>Plan</strong>The Emergency Action <strong>Plan</strong> should include step by step instructions to helpmanagement/staff/carers manage this particular individual’s seizure/s. It should alsoindicate the specific circumstance in which an ambulance should be called.EMERGENCY ACTION PLANThe Epilepsy Foundation of Victoria Inc recommends regular consultation with the treatingdoctor to assist with details for this emergency action plan. Information must be current andchanges need to be communicated to carers. For additional information refer to “When AnAmbulance Is Called In An Emergency Situation for Epilepsy.”Date of Last Seizure Type of Seizure/s Did an Ambulance Attend?New Form Required