Child Long Term Medication & Chronic Illness Health Record

Child's Firstname

Child's Surname

Date of Birth

Gender

Which condition does your child have?

(PLEASE USE BLANK SPACES FOR ADDITIONAL SIGNS)

ALLERGY ANAEMIA ASTHMA

ECZEMA HEARING PROBLEMS DIABETES

HEART PROBLEMS KIDNEY DISEAS EPILEPSY

What happens to your child when s/he has a crisis related to this condition?

Action Plan 1

Action Plan 2

Action Plan 3

Medication required for this condition?

Dose

Frequency

NB: ONLY PRESCRIPTION FOR THE CHILD NAMED WILL BE ADMINISTERED.

EMERGENCY CONTACT (OTHER THAN PARENT)

Relationship to Child

Telephone Number

Child's Doctor

Telephone

Parent's Firstname

Parent's Surname

Date

THIS FORM WILL BE KEPT IN THE CHILD’S FILE AND THE STAFF OF CENTRE WILL BE MADE AWARE OF THE INFORMATION. IT WILL BE CHECKED BEFORE ACTION IS TAKEN.

PLEASE ATTACH A LETTER FROM THE CHILD’S DOCTOR TO THIS FORM.

Please note: Prescription medicine will not be administered if labelled for anyone other than the child named on this form. Please ensure the medication (prescribed and over the counter) is clearly labeled with your child’s name, Date of Birth and dosage, frequency required.

For more information refer to Medical Conditions Policy, Administration of Authorised Medication Policy located in the foyer.