HEALTH SUMMARY

Case Name	Case ID #
Child/Youth	Child ID #
Child's Age	Child's D.O.B.	Primary Language
Emergency Contact Name & Relationship	Phone
Phone
Current Health Care Providers
Provider Type	Name	Phone	Last Exam/Visit
Primary Care Medical Provider
Dentist
Mental/ Behavioral Health Professional	Psychiatrist
Therapist
Medical Provider	Specialist
Specialist
Specialist
Attach Most Current Immunization Records
Complex Medical Needs	CLASSIFICATION
Yes No	If Yes, Level	1	2	3	4
Diagnoses Acute/Chronic – Past Procedures – Physical Exams
1.	Baseline Physical Findings:
2.
3.	Baseline Vital Signs:
4.
Synopsis:	Baseline Neurological Status:

Allergies Epi Pen: Yes No
Medication/Foods to be Avoided:	Associated Adverse Reactions:
1.
2.
3.
Procedures to be Avoided:	and Why:
1.
2.
3.
Common Presenting Problems/Findings with Specific Suggested Managements
Problem:	Suggested Diagnostic Studies:	Treatment Considerations:
Medications (Current)	Date Started:
Dose:	Prescriber:	Purpose:
Special Equipment/Dietary Needs (glasses, hearing aids, nebulizer, diabetic supplies, formula type, etc.)
Comments on Child, Family, or Other Specific Medical Issues

Completed by:	Date: