Appendix L: Individualized Health Care Plan

Individualized Health Care Plan_[1]

Child: ______________________________________Birthdate: _______________________

Parent(s) or Guardian(s): ______________________________________________________

Phone #: _________________________ Alternate Phone #:__________________________

Primary Health Care Provider: __________________________________________________

Primary Health Care Provider Phone #: ___________________________________________

DIAGNOSIS:

1. ________________________________________________________________________
2. ________________________________________________________________________
3. _______________________________________________________________________

Routine Care

Emergency Care

Call parents for: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

While waiting for parent/guardian or medical help to arrive: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Give as Needed or Emergency Medication for: _______________________________________

Get medical attention for: ­­­­­­­­­­­­___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CALL 911 (Emergency Medical Services) FOR: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date plan completed: _______________ Plan will be updated on or before: ________________

Parent(s) or Guardian(s):

___________________________________          ______________________________________

Staff Name(s) & Title(s):

___________________________________          ______________________________________

___________________________________          ______________________________________

Health Care Provider Name(s) & Title(s):

___________________________________          ______________________________________

___________________________________          ______________________________________