Health Plan Template

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South Bend Community School Corporation
Special Education Services
 
Health Plan
Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________
School: __________________________________ Grade: ____________
Age: ____________
School Nurse: _____________________________ Emergency Phone #: _______________________
Doctor: __________________________________ Hospital Preference: ________________________
Diagnosis (es):
Medication needs/Dosages:
Allergies:
Medical Equipment:
Nutrition and Feeding:
Skin Care Dressings:
Tubes:
Bowel/Bladder Care:
O2 Needs:
Orthopedic Equipment Usage:
Respiratory Treatments:
Suction:
OT/PT/SLP Service:
Ventilator
Comments:
8/18/12

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