FLORIDA DEPARTMENT OF HEALTH IN MIAMI-DADE COUNTY

SCHOOL HEALTH PROGRAM

HEALTH HISTORY AND CONSENT-SEIZURE DISORDER

Student: _______________________________ DOB____________ Teacher: ______________ Grade: ________

School: ____________Parent/Guardian & Phone(s): _________________________________________________

Physician & Phone: ______________________________________________ School Year: ________________

KNOWN ALLERGIES: ____________________________________________________________________

Dear Parent/Guardian:

School records or medical information indicates your child has seizure disorder. In order to attend to your child’s health and safety, the school requires a health history. Please return this form to the nurse as soon as possible. It will become part of your child’s confidential school health record.

__________________________ __________________________________ _________________

School Nurse Phone number Date

1. When was your child’s last seizure? How often do they occur? _____________________________________________________

When was the last time your child saw the doctor? ______________________________________________________________

Has your child ever been hospitalized for seizures? No Yes (When?) ____________________________________________

Check or list your child’s triggers for seizures:

Missed Medication Lack of Sleep Illness or fever Poor Nutrition Stress

Bright Lights Menstrual Cycle Violent Movements/Fighting Other ___________________________________________

Please describe (AURA) any unusual behavior (if any) before a seizure occurs :________________________________________

Describe your child’s typical seizure activity. Please include usual seizure activity, duration, and part(s) of the body involved in the seizure:_________________________________________________________________________________________________

_______________________________________________________________________________________________________

Please check the type of seizure disorder your child has:

Simple Partial Complex Partial

Generalized Tonic Clonic (Grand Mal) Absence (Usually less than 20 seconds) Unknown

6. Please list the medications your child takes for seizures:

Name of Medication	Dosage	Time

______________________________________________________________________________________________

______________________________________________________________________________________________

7. List any other medications your child takes?

______________________________________________________________________________________________

______________________________________________________________________________________________

8. Self-Care

Is your child able to monitor their symptoms and report changes?	No	Yes

Does your child:

Know what medication to take	No	Yes

Know what activity/dietary limitations	No	Yes

Tell an adult immediately, if not feeling well	No	Yes

Wear a medical alert bracelet, necklace, or watchband	No	Yes

CONSENT

Please circle your response and sign: I do give the School Nurse my permission to share information relevant to my child’s medical status with school staff on a “need to know” basis, if she/he determines that this information is necessary to assure my child’s health and safety.

PARENT/GUARDIAN SIGNATURE: _____________________________________ DATE: ____________________