Family Medical Information and
Important Contacts
This section includes pages to provide your health care
team with a personal profile of your child and family.
These forms will help providers learn more about your
child and family. Additionally, important contacts are
kept in this section.
The Family to Family Health Information Center at Raising Special Kids • 5025 E. Washington St. #204, Phoenix, AZ 85034
www.raisingspecialkids.org • [email protected] • 602-242-4366 • 800-237-3007 • Fax 602-242-4306 August 09
Emergency Preparedness Children with special health care needs may have complex and unique medical histories and conditions that affect decisions about their proper treatment during an emergency. Therefore, it is critically important that emergency health providers and “first responders” (paramedics, hospital ER doctors, school nurses, etc.) can get an up-to-date and complete record of your child’s medical issues.
Since emergencies don’t always happen at home when a knowledgeable family member can explain a child’s health condition, the American Academy of Pediatrics and the American College of Emergency Physicians have created an “Emergency Information Form for Children with Special Needs”. This 2-page Emergency Information Form provides important details about a child’s health, including:
family & emergency contacts
diagnosis/diagnoses
doctors & specialists
prior medical procedures
baseline physical condition & vital signs
current medications
allergies
immunizations
recommended treatments for common health issues
Get the Form:
Blank Form (to print then complete by hand): http://goo.gl/aTVusD Interactive Form (to complete online and print): http://www2.aap.org/advocacy/chfdataform.pdf
Complete the Form: Fill in as many of the answers as you can. Then, take the Form to your child’s primary care doctor and specialists to help you with the rest of the information. Be sure to fill in the date the form was completed (box in the upper right-hand corner) so you can check if the information is current.
The Family to Family Health Information Center at Raising Special Kids • 5025 E. Washington St. #204, Phoenix, AZ 85034
www.raisingspecialkids.org • [email protected] • 602-242-4366 • 800-237-3007 • Fax 602-242-4306 August 09
Share the Form: Make copies of the completed form and keep a copy in places like: doctors & specialists offices local hospital emergency room school or daycare child’s backpack (and luggage when
traveling) home on the refrigerator
parent’s workplace parent’s wallet family’s car home of emergency contact person
listed on the form
Update the Form: Review the form and make any changes every year -- or sooner, if there are any changes to your child’s health condition or treatment (medications, diagnoses, surgeries, etc.).
Using the Form at School/Daycare: Since children spend many hours away from their families, it’s a good idea to have an emergency plan in place for school or daycare. To develop an emergency plan for your child:
1) Complete the Emergency Information Form 2) Provide copies to your child’s:
school nurse or designated health personnel classroom teacher principal school bus driver
3) Designate an adult to be responsible for child in case of emergency (evacuation, etc.) – and, a back-up person in case that adult is unavailable.
4) Practice evacuation procedures (e.g. fire drill) annually with designated adults. 5) Update the Emergency Information Form as needed.
This school emergency plan and Emergency Information Form should be included in your child’s Individualized Education Plan (IEP) or 504 Plan.
This publication was developed in part with funding from the Health Resources and Services Administration (HRSA)/Maternal and Child Health Bureau (MCHB)/Division of Services for Children with Special Health Care Needs (DSCSHN) through Grant # H84MC07942
Emergency Information Form for Children With Special Needs
Name: Birth date: Nickname:
Home Address: Home/Work Phone:
Parent/Guardian: Emergency Contact Names & Relationship:
Signature/Consent*:
Primary Language: Phone Number(s):
Physicians:
Primary care physician: Emergency Phone:
Fax:
Current Specialty physician: Emergency Phone:Specialty:
Fax:
Current Specialty physician: Emergency Phone:Specialty:
Fax:
Anticipated Primary ED: Pharmacy:
Anticipated Tertiary Care Center:
Diagnoses/Past Procedures/Physical Exam:
1 .
2.
3.
4.
Synopsis:
Baseline physical findings:
Baseline vital signs:
Baseline neurological status:
Date formcompleted
By Whom
Revised Initials
Revised Initials
Last name:
*Consent for release of this form to health care providers
Management Data:
Allergies: Medications/Foods to be avoided and why:
1.
2.
3.
Procedures to be avoided and why:
1.
2.
3.
Common Presenting Problems/Findings With Specific Suggested Managements
Problem Suggested Diagnostic Studies Treatment Considerations
Immunizations
Dates
DPT
OPV
MMR
HIB
Dates
Hep B
Varicella
TB status
Other
Antibiotic prophylaxis: Indication: Medication and dose:
Diagnoses/Past Procedures/Physical Exam continued:
Medications:
1.
2.
3.
4.
5.
6.
Significant baseline ancillary findings (lab, x-ray, ECG):
Prostheses/Appliances/Advanced Technology Devices:
Comments on child, family, or other specific medical issues:
Physician/Provider Signature: Print Name:
Last name:
© American College of Emergency Physicians and American Academy of Pediatrics. Permission to reprint granted with acknowledgement.
Child and Family Information
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human
Services (HHS) under the Family to Family Health Information Centers, CFDA NO.93.504. The information, content, and conclusions should not be
construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals,
and Raising Special Kids. For information on this NICU Parent Resource Manual, contact Raising Special Kids at 1-800-237-3007 or at
Child’s Name: Date of Birth:
Family Information
Language: Religion:
Diagnosis:
Blood Type:
Child’s Legal Guardian: ☐ Mom ☐ Dad ☐ Grandparent ☐ Other
Guardian’s Name (if other than Mom or Dad):
Address:
Home Phone: Email:
Family Members
Mother’s Name:
Address:
Email:
Home Phone: Cell Phone:
Father’s Name:
Address:
Email:
Home Phone: Cell Phone: ___________________
Other Household Members:
Child and Family Information
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human
Services (HHS) under the Family to Family Health Information Centers, CFDA NO.93.504. The information, content, and conclusions should not be
construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals,
and Raising Special Kids. For information on this NICU Parent Resource Manual, contact Raising Special Kids at 1-800-237-3007 or at
Other important family members and/or supportive friends:
What is the best way to contact them?
Does your child have more than one residence? ☐Yes ☐No
If yes, please explain:
Additional Parent(s)/Guardian(s)
Name: Relationship to Child:
Address:
Email:
Home Phone: Cell Phone:
Name: Relationship to Child:
Address:
Email:
Home Phone: Cell Phone:
Emergency Contact
Name: Relationship:
Address:
Home Phone: Cell Phone:
Phone list of Important Contacts for Child
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Name Specialty Phone Number/
Fax Number
Address Email
Phone list of Important Contacts for Child
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Name Specialty Phone Number/
Fax Number
Address Email
Medical Supplies/Equipment
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Insurance Company Responsible for Supplies: Insurance Phone:
Policy #: Authorization #:
Description Amount Supplier /
Manufacturer
Model Number Phone Number Authorizing Doctor
Medical Supplies/Equipment
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Insurance Company Responsible for Supplies: Insurance Phone:
Policy #: Authorization #:
Description Amount Supplier /
Manufacturer
Model Number Phone Number Authorizing Doctor
Medical Supplies/Equipment
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Insurance Company Responsible for Supplies: Insurance Phone:
Policy #: Authorization #:
Description Amount Supplier /
Manufacturer
Model Number Phone Number Authorizing Doctor
Medical Supplies/Equipment
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Insurance Company Responsible for Supplies: Insurance Phone:
Policy #: Authorization #:
Description Amount Supplier /
Manufacturer
Model Number Phone Number Authorizing Doctor
Communication Log for Therapists / In-Home Providers
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Keep track of what you have discussed with your child’s various therapists and caregivers.
Date Time in Time Out Person/Agency Phone Number Notes
Communication Log for Therapists / In-Home Providers
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Keep track of what you have discussed with your child’s various therapists and caregivers.
Date Time in Time Out Person/Agency Phone Number Notes
Communication Log for Therapists / In-Home Providers
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Keep track of what you have discussed with your child’s various therapists and caregivers.
Date Time in Time Out Person/Agency Phone Number Notes
Communication Log for Therapists / In-Home Providers
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Keep track of what you have discussed with your child’s various therapists and caregivers.
Date Time in Time Out Person/Agency Phone Number Notes
Communication Log for Therapists / In-Home Providers
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Keep track of what you have discussed with your child’s various therapists and caregivers.
Date Time in Time Out Person/Agency Phone Number Notes
Communication Log for Therapists / In-Home Providers
This publication is partially supported by the Health Resources and Services Administration (HRSA) of the U.S Department of Health and Human Services (HHS) under the Family to Family Health Information Centers, CFDA
NO.93.504. The information, content, and conclusions should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S Government
And in part with grants from Dignity Health for the Smooth Way Home Project with Feeding Matters, Southwest Human Development Easter Seals, and Raising Special Kids. For information on this NICU Parent Resource
Manual, contact Raising Special Kids at 1-800-237-3007 or at [email protected]
Keep track of what you have discussed with your child’s various therapists and caregivers.
Date Time in Time Out Person/Agency Phone Number Notes