Patient’s Name

Caregiver

This patient is being treated for a seizure disorder.

Facility HoursFacility Hours

(regarding facility activites, etc.)(regarding facility activites, etc.)

Keep patient safe

Turn patient on side

this patient is defined as:

Does patient have a

Caregiver Signature

Nurse/Physician Signature

Contact nurse at

Notify caregiver or emergency contactPatient has repeated seizures without regaining consciousnessPatient is injured or has diabetesPatient has a first time seizurePatient has breathing difficultiesPatient has a seizure in water

Stay with patient until fully conscious

Patient’s response after a seizure: