Personal Health Records / Care Notebooks
Notebooks - Templates & Completable Forms
Center for Medical Home Improvement
CMHI promotes the medical home as a family-centered “way of doing things” for CSHCN; this includes how practices partner with, respond to, and care for children, especially those with or at risk for developing special health care needs. CHMI makes the following sample plans available:
- Medical Emergency Care Plans
pdf | - Action Plans pdf |
- All 3 Files Combined pdf |
Other downloads from Center for Medical Home Improvement
- Keene Health Care Plan
MS Word |
The National Center for Medical Home Initiatives
Integrated Services Care Plan: PDF | MS Word
A comprehensive assessment that includes: demographics, current problems with status, routine health maintenance, specialty care, medical support services, hospital care, education, rehab services, pharmacy needs, medical equipment/home care, community services, and a parent/caregiver signature page. Developed by the PA Medical Home Program - EPIC IC.
Emergency Preparedness
for Children with Special Health Care Needs
To facilitate prompt and appropriate emergency care for children with special health care needs, the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) have developed an Emergency Information Form and other materials which can be used as a tool to transfer critical information about these children. It is hoped that the form will gain acceptance and be utilized by primary caregivers and specialists so that emergency physicians may have access to vital information when emergencies occur.
- Blank Emergency Information Form PDF |
- Blank Interactive Emergency Information Form MS Word |
- Sample Emergency Information Form PDF |
- Sample Emergency Information Form in Spanish PDF |
- Instructions for Parents on Using the Form
Website |
- Patient At Risk
http://www.wiaap.org/patient-at-risk.php
The Patient at Risk Program is a free, web-accessible database for Emergency Information Forms (EIFs) for patients and families across Wisconsin. Patient at Risk gives emergency medical providers fast access to information about your child's health
MyPHR Forms - Adult Forms
This fifteen-page form contains space for recording: Allergies, Identification, Medical history, Major illness/operations, Medications, Infectious diseases, Immunizations, Health maintenance, Devices and prostheses, Eye information, Healthcare documents, and Family medical history.
Child Form
This five-page form contains space for recording: Allergies, Identification, Birth date, Growth and development, Immunizations, Medications, and Infectious diseases.
Health Forms and Records by Dr. Marie Savard
Dr. Savard's Forms
Dr. Savard is Author of How to Save Your Own Life: The Savard System for Managing--and Controlling--Your Health Care and The Savard Health Record.
Care Notebook - Washington
The Care Notebook and Care Organizer are tools for families who have children with special health care needs developed in Washington State Children's Hospital and Regional Center. Families use Care Notebooks to keep track of important information about their child's health and care. This makes it easier to find and share key information with their child's care team. These tools are available in English, Spanish, Russian, and Vietnamese.
Build Your Own Care Notebook
http://www.medicalhomeinfo.org/for_families/care_notebook/
Extensive list of sample plans to download from the National Center of Medical Home Initiatives from the American Academy of Pediatrics. Organized by topic area.
Other Templates:
- To Do List MS Word |
- Blood Glucose Log
MS Excel | - Blood Pressure Log MS Excel |
- Daily Food Log MS Word |
- My Health Record MS Excel |