27: Appendix L- Individualized Health Care Plan

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Appendix L: Individualized Health Care Plan⁷⁶⁹

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):

___________________________________ ______________________________________