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)