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: