Florida Department of Health in Miami-Dade

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

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:

Focal Onset Aware Focal Onset Impaired Awareness Generalized Tonic Clonic Absence Unknown

Please list the medications your child takes for seizures:

Name of Medication	Dosage	Time

______________________________________________________________________________________________

______________________________________________________________________________________________

9. List any other medications your child takes.

______________________________________________________________________________________________

______________________________________________________________________________________________

10. 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 /do not 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: ____________________