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HTML Preview Individual Health Care Plan page number 1.
1
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.
Allergi
es:
Equipment:
Type of equipment/company providing equipment/
date prescribed/
new equipment needed
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