Skip to main content
Social Sci LibreTexts

27: Appendix L- Individualized Health Care Plan

  • Page ID
    69656
  • \( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \) \( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash {#1}}} \)\(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\) \(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\)

    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):

    ___________________________________ ______________________________________

    ___________________________________ ______________________________________


    This page titled 27: Appendix L- Individualized Health Care Plan is shared under a CC BY license and was authored, remixed, and/or curated by Jennifer Paris.