Individual Health Care Plan

Individual Healthcare Plan

Name of School / Setting: Windlesham School & Nursery

To get started, replace this text with your own.

Child's Name:

Child's Year:

Date of Birth:

Address of Child:

Medical Diagnosis or condition:

Today's Date:

Review Date: To be completed by school

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Family Contact Information

Name:

Relationship to child

Contact Phone Number (Work):

Contact Phone Number (Home/Mobile):

Name of additional emergency contact:

Relationship to child:

Contact Phone Number (Work):

Contact Phone Number (Home/Mobile):

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Clinic / Hospital Contact:

Name:

Phone Number:

GP Name:

GP Phone Number:

Who is responsible for providing support in school: (School to complete)

Describe medical needs and give details of child's symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc.

Name of medication, dose, method of administration, when to be taken, side effects, contra-indications, administered by/self-administered with/without supervision.

to symptoms, Daily

Daily Care Requirements:

Specific Support for the pupils educational, social and emotional needs:

Arrangements for school trips/visits will be agreed with parents

Other information relevant:

Describe what constitutes an emergency and the action to take if this occurs. What are the symptoms or signs to look out for?

The support team, with assistance from SLT, will be responsible for an emergency.

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This section is to be completed by school staff - parents need not fill this in.

Plan developed with: (School to complete)

Staff training needed/undertaken - who, what, when

Form copied to: