Individual Health Care Plan

Individual Health Care Plan - Duchy Preschool, Bradninch
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Room
Child's Address

Street Address

Street Address Line 2

CityState / Province

Post Code
Medical diagnosis or condition
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Family Contact Information
Contact 1

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact 2

First NameLast Name
Relationship to Child
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Clinic/Hospital Contact
Name

First NameLast Name
Clinic/Hospital details
Name and address of clinic/hospital
Phone number
Format: (000) 000-0000.
GP Details
Name and address of GP
GP Phone Number
Format: (000) 000-0000.
Who is responsible for providing support in the setting?
This questions to be discussed with the setting
Describe medical needs and give details of child’s symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc...
Name of medication, dose, method of administration, when to be taken, side effects, contra-indications, administered by/self-administered with/without supervision:
Daily Care Requirements:
Specific support for the pupil’s educational, social and emotional needs:
Arrangements for school visits/trips etc...
Any other relevant information?
Describe what constitutes an emergency, and the action to take if this occurs:
Office Use only

The section below to be completed by the setting
Review Date: (office use only)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearOffice use only
Plan developed with: (office use only)
Office use only
Staff training needed/undertaken – who, what, when? (office use only)
Office use only
Form copied to: (office use only)
Office use only
Should be Empty:

Individual Health Care Plan - Duchy Preschool, Bradninch

Family Contact Information

Clinic/Hospital Contact

Office Use only