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

Medication When How Much How Possible Side Effects

 

Describe accommodations the child needs in daily activities
Diet or Feeding

 

Naptime/Sleeping

 

Toileting

 

Outdoor Activities/Field Trips

 

Transportation

 

Other

 

Emergency Care

Call parents for: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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

Give as Needed or Emergency Medication for: _______________________________________

Medication When How Much How Possible Side Effects
 

 

 

 

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):

___________________________________          ______________________________________

___________________________________          ______________________________________

License

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Safety, Health and Nutrition in Early Childhood Education Copyright © by Kelly McKown is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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