Appendix L: Individualized Health Care Plan
Kelly McKown
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:
- ________________________________________________________________________
- ________________________________________________________________________
- _______________________________________________________________________
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):
___________________________________ ______________________________________
___________________________________ ______________________________________
