Section IV "Seizure Report Flow Chart" - New Mexico

What Is Section IV?

This is a legal form that was released by the New Mexico Department of Health - a government authority operating within New Mexico. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 1998;
  • The latest edition provided by the New Mexico Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Section IV by clicking the link below or browse more documents and templates provided by the New Mexico Department of Health.

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SEIZURE REPORT
FLOW CHART
Student Name: _____________________________________ ID #: _____________________ Birthdate: _________________
School: _____________________________________ Teacher Name: ________________________Grade: ______________
DATE OF EACH SEIZURE
TIME OF ONSET
TOTAL TIME INVOLVED
A. Observation Before Seizure
Cries Out
Other
B. Observation During Seizure
Extremity Involvement
o
Both upper & lower
o
Arms affected
right
left
o
Legs affected
right
left
o
Straight
o
Bent
o
Stiff
o
Limp
o
Verbal Sounds
before
during
o
Face twitching
o
Mouth
opened
closed
grimacing
o
Drooling
o
Vomited
o
Eye movement
staring
opened
closed
fluttering
rolled back
o
Head
turned right
turned left
turned down
o
Hyper-extended back
nodding
Continued on next page
NMSHM – Section IV (07/1997)
NMSHM – Section IV (06/1998)
SEIZURE REPORT
FLOW CHART
Student Name: _____________________________________ ID #: _____________________ Birthdate: _________________
School: _____________________________________ Teacher Name: ________________________Grade: ______________
DATE OF EACH SEIZURE
TIME OF ONSET
TOTAL TIME INVOLVED
A. Observation Before Seizure
Cries Out
Other
B. Observation During Seizure
Extremity Involvement
o
Both upper & lower
o
Arms affected
right
left
o
Legs affected
right
left
o
Straight
o
Bent
o
Stiff
o
Limp
o
Verbal Sounds
before
during
o
Face twitching
o
Mouth
opened
closed
grimacing
o
Drooling
o
Vomited
o
Eye movement
staring
opened
closed
fluttering
rolled back
o
Head
turned right
turned left
turned down
o
Hyper-extended back
nodding
Continued on next page
NMSHM – Section IV (07/1997)
NMSHM – Section IV (06/1998)
SEIZURE REPORT
FLOW CHART (CONTINUED)
Student Name: ________________________________________________________________________________________
DATE OF EACH SEIZURE
Body Trunk
o
rigid
o
limp
o
sitting
o
laying
o
trembling
o
jerking
o
standing
Skin Color
o
pale
o
gray
o
blue
o
red (flushed)
Breathing
o
difficulty during
o
difficulty after
o
15 seconds
o
1 minute
o
longer (give time)
Incontinent
o
urine
o
bowels
Observations after Seizure
o
drowsy
o
confused
o
sleep (give length of time)
Other
o
injury (elaborate)
o
school nursed called
o
health assistant called
o
parent called
o
child taken home (by whom)
o
doctor called
o
911 called
Responder’s Initials
NMSHM – Section IV (07/1997)
NMSHM – Section IV (07/1998)
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