INDIVIDUALIZED HEALTH CARE PLAN

NAME: ______________________ DOB: _________ SEX: _____ ALLERGIES: _________________ PHYSICIAN: ___________________

RELEVANT DIAGNOSIS: ________________________________________________________________________________________________

DIET: __________________ MOBILITY: __________________________ EQUIPMENT: ___________________________________________

MEDICAL HISTORY: ____________________________________________________________________________________________________

MEDICATION/TREATMENT: ______________________________________________________________________________________________

SIGNATURE: _________________________ SIGNATURE: _________________________ SIGNATURE: _________________________

(Parent) (Student) (School Nurse)

LIAISON WITH FAMILY: ______________________________ DATES OF MEDICAL ORDERS: _____________/___________/__________

DATE

HEALTH PROBLEM/NURSING DIAGNOSIS

STUDENT GOALS

INTERVENTION AND RESPONSIBLE PERSON

EVALUATION AND TIMELINE

C-19