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Sample Individual Health Plan
Name: Date of Last Revision:
Date of Birth:
Address/Phone/Parents:
Primary Doctor:
Address/Phone:
Principal Diagnosis:
Problem List: Consultants/Hospital/Phone/Date Last Seen:
1.
2.
3.
Hospital Admissions in the last 12 months
Reason/Outcome/Discharge Date:
1.
2.
Curre nt Medications:
Dosage/Frequency/Method of Administration/Reason for taking/Prescribed by/Date
started/effectiveness/side effects
1.
2.
3.
Allergies:
Equipment:
Type of equipment/company providing equipment/date prescribed/new equipment needed