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CH-15
SEP 08 Page 1 of 2 Pages.
CARE PLAN FOR CHILDREN WITH SPECIAL HEALTH NEEDS
-To be completed by a Health Care Provider-
Today’s Date
Child’s Full Name
Date of Birth
Parent’s/Guardian’s Name
Telephone No.
( )
Primary Health Care Provider
Telephone No.
( )
Specialty Provider
Telephone No.
( )
Specialty Provider
Telephone No.
( )
Diagnosis(es)
Allergies
ROUTINE CARE
Medication To Be
Given at Child Care
Schedule/Dose
(When and How Much?)
Route
(How?)
Reason
Prescribed
Possible
Side Effects
List medications given at home:
NEEDED ACCOMMODATION(S)
Describe any needed accommodation(s) the child needs in daily activities and why:
Diet or Feeding:
Classroom Activities:
Naptime/Sleeping:
Toileting:
Outdoor or Field Trips:
Transportation:
Other:
Additional comments: