{"id":530,"date":"2026-09-21T10:10:28","date_gmt":"2026-09-21T14:10:28","guid":{"rendered":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/accessible-docs\/seizure-medical-management-plan-mmp-pdf\/"},"modified":"2026-09-21T13:49:42","modified_gmt":"2026-09-21T17:49:42","slug":"seizure-medical-management-plan-mmp-pdf","status":"publish","type":"savoy_document","link":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/accessible-docs\/seizure-medical-management-plan-mmp-pdf\/","title":{"rendered":"Seizure-Medical-Management-Plan-MMP.pdf"},"content":{"rendered":"

Medical Management Plan for Seizure Disorder<\/h1>\n

Student Information<\/h2>\n

School Year:<\/strong> ________________<\/p>\n

Student Name:<\/strong> <\/p>\n

Date of Birth:<\/strong> <\/p>\n

Physician\u2019s Name:<\/strong> <\/p>\n

Phone #:<\/strong> <\/p>\n

Address:<\/strong> <\/p>\n

Fax #:<\/strong> <\/p>\n

Medical History<\/h2>\n

List Known Allergies:<\/strong> <\/p>\n

Type of seizures:<\/strong> <\/p>\n

Please list all medications (Home & School):<\/strong> <\/p>\n

Are medications needed during school hours?<\/strong> Yes \/ No<\/p>\n

If yes, please list:<\/strong><\/p>\n\n\n\n\n\n
Name of Medication<\/th>\nPrescribed Dose\/Route<\/th>\nWhen to Use<\/th>\n<\/tr>\n<\/thead>\n
<\/td>\n<\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

If Diastat or Midazolam is ordered, it should be given:<\/strong><\/p>\n

    \n
  • At onset of seizure<\/li>\n
  • Minutes into seizure after<\/li>\n
  • Seizures in a row<\/li>\n<\/ul>\n

    Is VNS used?<\/strong> (if yes please instruct) Yes \/ No<\/p>\n

    Are there activity limits?<\/strong> (if yes please describe) Yes \/ No<\/p>\n

    Is protective equipment required?<\/strong> (if yes please describe) Yes \/ No<\/p>\n

    Nursing services are recommended for the care of this student during the school day.<\/p>\n

    Physician’s Signature:<\/strong> Date:<\/strong> <\/p>\n

    Parent to Complete<\/h2>\n
      \n
    1. When was the last seizure?<\/li>\n
    2. At what age did the seizure activity begin?<\/li>\n
    3. Describe the seizure?<\/li>\n
    4. How often do seizures occur?<\/li>\n
    5. How long do the seizures normally last?<\/li>\n
    6. Has the seizure ever lasted longer than 5 minutes? Yes \/ No<\/li>\n
    7. If yes, how was it handled?<\/li>\n<\/ol>\n

      Continued Seizure Plan for (Student Name)<\/h2>\n
        \n
      1. Does your child lose bowel or bladder control during a seizure? Yes \/ No<\/li>\n
      2. Has your child ever turned blue or stopped breathing during a seizure? Yes \/ No<\/li>\n
      3. If yes, how was it handled?<\/li>\n
      4. Has your child ever required hospitalization due to a seizure? Yes \/ No<\/li>\n
      5. If yes, please explain:<\/li>\n
      6. Is there anything that seems to trigger a seizure? Yes \/ No<\/li>\n
      7. If yes, please list:<\/li>\n
      8. Does your child experience an aura before a seizure? Yes \/ No<\/li>\n
      9. If yes, please explain:<\/li>\n<\/ol>\n

        Other considerations that will assist the school in providing care for your child:<\/strong><\/p>\n

        Is your child compliant with their current treatment regime?<\/strong> Yes \/ No<\/p>\n

        Does your child function independently with medication administration?<\/strong> Yes \/ No<\/p>\n

        Are there any activity restrictions for your child?<\/strong> Yes \/ No<\/p>\n

        If yes, please list:<\/strong><\/p>\n

        Authorization for Health Care Provider and School Nurse to Share Information<\/h2>\n

        I authorize my child\u2019s school nurse to assess my child as it relates to his\/her special health care needs and to discuss these needs with my child\u2019s physician as needed throughout the school year. I understand this is for the purpose of generating a health care plan for my child. I understand I may withdraw this authorization at any time and that this authorization must be renewed annually.<\/p>\n

        As the parent or guardian of the student named above, I request that the principal or principal\u2019s designee assist in the administration of medication\/treatment prescribed for my child. I understand that under provisions of Florida Statute 1006.062, there shall be no liability for civil damages as a result of the administration of medication when the person administering such medication acts as an ordinarily reasonable, prudent person would have acted under the same or similar circumstances. I also grant permission for school personnel to contact the physician listed above if there are any questions or concerns about the medication. I have read the guidelines and agree to abide by them. I authorize the physician to release information about this condition to school personnel.<\/p>\n

        Parent\/Guardian Signature:<\/strong> Print Name:<\/strong> Date:<\/strong> <\/p>\n

        Parent\/Guardian Cell:<\/strong> <\/p>\n

        Work:<\/strong> <\/p>\n

        Parent\/Guardian:<\/strong> Cell: Work:<\/strong> <\/p>\n","protected":false},"author":429,"template":"","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-530","savoy_document","type-savoy_document","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/530","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document"}],"about":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/types\/savoy_document"}],"author":[{"embeddable":true,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/users\/429"}],"version-history":[{"count":0,"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/savoy_document\/530\/revisions"}],"wp:attachment":[{"href":"https:\/\/www-lms.stjohns.k12.fl.us\/clinic\/wp-json\/wp\/v2\/media?parent=530"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}