Emergency Action Health Care Plan Template printable pdf download

Student’s

EMERGENCY ACTION HEALTH CARE PLAN (Part 1)

( TO BE COMPLETED BY PARENT)

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Student Name___________________________________ _DOB_________ School__________________

Allergies______________________________________________________Grade____________________

Parent/Guardian______________________________ Phone (H)____________Phone (W)____________Phone(Cell)____________

Address___________________________________________City________________________________Zip___________________

Emergency contact _____________________________ Relationship______________________ Phone_______________________

Name of physician_________________________________________ Office phone number ________________________________

TO BE COMPLETED BY THE PHYSICIAN:

DIAGNOSIS: ___________________________________________________________________________

POSSIBLE SYMPTOMS__________________________________________________________________

__________________________________________________________________

EMERGENCY ACTION IS NECESSARY IF THE STUDENT HAS THE FOLLOWING SYMPTOMS!!!

_______________________________________________________________________________________

A. Steps to take as emergency support:

1. ____________________________________________________________________________

2. ____________________________________________________________________________

3. ____________________________________________________________________________

4. ____________________________________________________________________________

B. May return to classroom if_____________________________________________________________

C. Contact parent/guardian if_____________________________________________________________

DAILY MANAGEMENT PLAN:

1. Identify areas which may aggravate the disorder (exercise, foods, etc):

_______________________

_________________________

_____________________________

2. Special Procedures__________________________________________________________________

______

Educational concerns_____________________________________________________

______

Physical Education concerns_______________________________________________

______

Sports Precautions concerns_______________________________________________

______

Recess Precautions______________________________________________________

______

Special Considerations on Field Trips________________________________________

______

Other _________________________________________________________________

_________________________________________________________________

Physician and Parent Signature Required. Please turn to the other side to complete and sign. Thank You! →→

Emergency Action Health Care Plan Template