Individual Health Plan

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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)

 

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