family medical information and important...

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:

Current Specialty physician: Emergency Phone:Specialty:

Anticipated Primary ED: Pharmacy:

Anticipated Tertiary Care Center:

Diagnoses/Past Procedures/Physical Exam:

Synopsis:

Baseline physical findings:

Baseline vital signs:

Baseline neurological status:

Date formcompleted

By Whom

Revised Initials

Last name:

*Consent for release of this form to health care providers

Management Data:

Allergies: Medications/Foods to be avoided and why:

Procedures to be avoided and why:

Common Presenting Problems/Findings With Specific Suggested Managements

Problem Suggested Diagnostic Studies Treatment Considerations

Immunizations

Varicella

TB status

Antibiotic prophylaxis: Indication: Medication and dose:

Diagnoses/Past Procedures/Physical Exam continued:

Medications:

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:

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

[email protected]

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

[email protected]

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:

Name: Relationship to Child:

Address:

Email:

Emergency Contact

Name: Relationship:

Address:

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

Name Specialty Phone Number/

Fax Number

Address Email

Medical Supplies/Equipment

Insurance Company Responsible for Supplies: Insurance Phone:

Policy #: Authorization #:

Description Amount Supplier /

Manufacturer

Model Number Phone Number Authorizing Doctor

Manufacturer

Communication Log for Therapists / In-Home Providers

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

family medical information and important...

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