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Attach this document to your Epilepsy Management Plan if Midazolam is prescribed

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Attach this document to your Epilepsy Management Plan if Midazolam is prescribed. This Emergency Plan should be completed by the prescribing doctor in consultation with the person and/or their family or carer. It must be attached to their epilepsy management plan which has been signed by their doctor. The Epilepsy Foundation recommends this plan be reviewed and signed by the person’s doctor annually.

Emergency Medication Management Plan
Midazolam (only to be administered by a trained person)

Midazolam Management Plan for (name):      


Date of birth:      

Administration method:

BUCCAL  INTRANASAL  Nasal atomiser  or Drip 

1. FIRST DOSE Midazolam

First dose =       mg       ml

For single seizures:

 As soon as a       (seizure type) begins

 If the       (seizure type) continues longer than       mins

For clusters of seizures:

 When       (number)       (seizure type) occur/s within       mins       hrs

 Other (please specify):      

Special instructions:      

2. SECOND DOSE Midazolam

Second dose =       mg       ml

 Not prescribed OR

 If the       (seizure type) continues for another       mins following the first dose

 When another       (number)       (seizure type) occur/s within       mins       hrs following the first dose

 Other (please specify):      

Special instructions:      

3. Maximum number of Midazolam doses to be given in a 24-hour period

Maximum number:      

4. Dial 000 to call the ambulance:

 Prior to administering Midazolam

 If the seizure has not stopped       minutes after giving the Midazolam

 Other (please specify):      

5. Describe what to do after Midazolam has been administered:


6. Prescribing doctor or specialist

Name of doctor:      




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7. Family/carers to complete

Any special instructions e.g. storage of medication, when on outings etc. or people to contact if emergency medication is given.








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Recommended midazolam storage information:

  • Keep out of reach of children

  • Protect from light and store at room temperature (below 25° C)

  • Regularly check the expiry date.

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