Individual Health Care Plan
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Name of agency/contact person/services provided Medical History: Dates of diagnoses/surgeries/hospitalizations/treatments/significant changes Review of Body Systems: Issue/How does it impact child/treatment/effectiveness/doctor treating/date of last doctor visit/unresolved issues/tests needed Nutrition/swallowing: Vision: Hearing: Communication: Respiratory Orthopedic: Dental: Cardiac: Renal: Endocrine: Gastrointestinal: Skin Integrity: Potential Problems : Changes/issues to watch/plan to address changes Team Goals: Date of last meeting/issues addressed/plan developed/timelines/follow- up/test results/insurance or coverage issues.
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