Individual Health Plan
This form must be used alongside the individual child’s registration form which contains emergency parental contact and other personal details.
Date completed: | ________________________________ | Review date: | ___________________________ |
Child’s details:
Full name: | Date of birth: | |||||
Address: | ________________________________________________________________ | |||||
_________________________________________________________________ | ||||||
Allergies: | __________________________________________________________________ | |||||
Medical condition/diagnosis | ____________________________________________________ | |||||
Medical needs and symptoms: | _______________________________________________________ | |||||
Daily care requirements: | ________________________________________________________ | |||||
Medication details (inc. expiry date/disposal) | ___________________________________________ | |||||
Storage of medication: | ___________________________________ | |||||
Procedure for administering medication: | _______________________________________ | |||||
Names of staff trained to carry out health plan procedures and administer medication: | ||||||
_____________________________________________________________________________ | ||||||
Other information: | ________________________________________ | |||||
Date risk assessment completed: | ____________________________________________ | |||||
Risk assessment details: | _____________________________________________ | |||||
Describe what constitutes an emergency for the child, what procedures will be taken if this occurs and the names of staff responsible for an emergency situation with the child: | ||||||
Child’s main carer(s)
1. Name: | __________________________ | Relationship to child: | ______________________ |
Contact number(s): | __________________________________________________________________________ | ||
2. Name: | __________________________ | Relationship to child: | _________________________ |
Contact number(s): | __________________________________________________________________________ |
General Practitioner’s details:
Name: | _________________________ | Contact number: | _______________________ |
Address: | _________________________________________________________________________ | ||
___________________________________________________________________________ |
Clinic of Hospital details (if app):
Name: | ___________________________ | Contact number: | __________________________ |
Address: | __________________________________________________________________________ | ||
_________________________________________________________________________ |
Declaration
I have read the information in this health plan and have found it to be accurate. I agree for the recorded procedures to be carried out:
Name of parent: | __________________________ | Date: | __________________________ |
Signature: | __________________________ | ||
Name of key person: | __________________________ | Date: | __________________________ |
Signature: | __________________________ | ||
Name of manager: | __________________________ | Date: | __________________________ |
Signature: | __________________________ | ||
Date: | __________________________ |
For children requiring life saving or invasive medication and/or care, for example, rectal diazepam, adrenaline injectors, Epipens, Anapens, JextPens, maintaining breathing apparatus, changing colostomy or feeding tubes, you must receive approval from the child’s GP/consultant, as follows:
I have read the information in this Individual Health Plan and have found it to be accurate.
Name of GP/consultant: | __________________________ | Date: | __________________________ |
Signature: | __________________________ |
To be reviewed at least every six months, or as and when needed.
Copied to parents and child’s personal file (with registration form)