Office for Genetics and People Special Health Care … for Genetics and People with Special Health...
31
Office for Genetics and People with Special Health Care Needs iTransition‐Health: Maryland Health Care Transition Program “Youth Transition to Adulthood” http://phpa.dhmh.maryland.gov/genetics/SitePages/Health_Care_Transition.aspx
Office for Genetics and People Special Health Care … for Genetics and People with Special Health Care Needs iTransition‐Health: Maryland Health Care Transition Program “Youth
Office for Genetics and People with Special Health Care Needs
iTransition‐Health Maryland Health Care Transition Program
ldquoYouth Transition to Adulthoodrdquo httpphpadhmhmarylandgovgeneticsSitePagesHealth_Care_Transitionaspx
201 W Preston Street ndash Baltimore Maryland 21201 Toll Free 1-877-4MD-DHMH ndash TTYMaryland Relay Service 1-800-735-2258
Web Site wwwdhmhmarylandgov
STATE OF MARYLAND
DHMH Maryland Department of Health and Mental Hygiene Larry Hogan Governor - Boyd Rutherford Lt Governor - Van Mitchell Secretary
Dear Parents and Caregivers This care notebook has been designed for you the parents and caregivers of a child with special health care needs You play an important role in your childrsquos care and doctors and nurses rely on you to give them information about your childrsquos health It is helpful to have all your childrsquos health care information organized and in one place so you can manage it easily Please use this health care notebook to adapt it to fit your childrsquos needs (see Creating Your Care Notebook on the next page) The Office for Genetics and People with Special Health Care Needs is also a resource for locating information on services you may need for your child Please call our Special Health Care Needs Resource Line on 410-767-1063 or 1-800-638-8864 for help You can also log on to our Resource Locator website httpspecialneedsdhmhmarylandgov to locate resources for children and youth with special needs If you have any questions please contact our parent resource coordinator Ms Angela Sitter at the above number She will be happy to assist you Regards
Donna X Harris Director Office for Genetics and People with Special Health Care Needs
Disclaimer This Patient Care Notebook is intended to assist you in maintaining and organizing your childrsquos medical record information You should take the Notebook to your childrsquos medical appointments and emergency visits to assist you in providing the necessary medical information to your childrsquos medical provider and to update information from the current doctor visit Please keep the Patient Care Notebook in a safe location The State of Maryland will not be responsible for loss or misplaced Patient Care Notebooks
The Youth2YoungAdult Care Notebook is adapted from the Teen Care Notebook created by Seattle Washington Hospital Research Foundation The Center for Child with Special Needs copy
2001 ‐ 2013 Seattle Childrens | All Rights Reserved
Are you a young person with a health condition that is beginning to take a more active role in your own health
The Youth2YoungAdult Care Notebook is a great way to organize information about your health
condition and treatments in one place You can also use it to share information with your parents
doctors nurses and other health care professionals
You can use the Youth2YoungAdult Care Notebook to
Track changes in your medicines or treatments
List phone numbers for health care providers and community organizations
Prepare for appointments
File information about your health history
Share new information with your primary doctor nurse and others
To set up your Youth2YoungAdult Care Notebook
Step 1 Gather your existing information Gather up any health information you and your parents
already have This may include reports from recent doctorrsquos visits immunization records recent
summary of a hospital stay this yearrsquos school plan test results or informational pamphlets
Step 2 Review the Care Notebook Which of these pages may help you keep track of information
about your health or care Choose the pages you like You can either print copies of any that you
think you will use and fill them out by hand or download a copy and save it to your computer so that
you can easily update the pages in the future
Step 3 Choose what to keep in the Care Notebook Decide what information you look up most
often and what information is needed by others Store other information in a file drawer or box where
you can find it if needed
Step 4 Assemble your Care Notebook The key is to make it easy for you to find the information
you need quickly and easily Some ideas in putting your Care Notebook together include using a 3-
ring binder with tabbed dividers to create your own sections pocket dividers to store reports andor
plastic pages to store business cards and photographs Or get an expandable folder if you are a
stuffer
Youth2YoungAdult Care Notebook Table of Contents
Keep Track of Your Contacts
Hospital Information List
MedicalDental Care Providers List
Home Care Providers List
Therapists List
Pharmacy List
Special Transportation List
Teen Family Information List
InsuranceFunding Sources List
Keep Track of Appointments and Care
Care Schedule
Appointment Log
MedicalSurgical Highlights
Lab WorkTestsProcedures List
Equipment and Supplies List
Medications List
Diet Tracking Form
Hospital Stay Tracking Form
Medical Bill Tracking
Make a Calendar
Notes
Document Your Care Plan
Getting to Know Me
Whats the Plan
Emergency Information Card
iTransition-Health Online Resources
Health Care Transition Resources for Youth
Health Care Transition Resources for Parents Families and Caregivers
Health Care Transition Resources for Providers
Health Care Transition Resources for Educators
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Family Information
Your Name Nickname Date of Birth Diagnosis Blood Type
Legal Guardian Address Phone
Family Members
Motherrsquos Name Address Email Daytime Phone Evening Phone Cell
Fatherrsquos Name Address Email Daytime Phone Evening Phone Cell
Siblingrsquos Name Age Name Age Name Age Name Age
Other Household Members
Important Family Information Language Spoken at Home Other Language(s) Interpreter Needed Yes No Interpreter Phone
Emergency Contact
Name Address Email Daytime Phone Evening Phone Cell
iTransition-Health Resources for Youth and Young Adults Check Your Skills
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Source Envisioning My Future A Young Personrsquos Guide to Health Care Transition from Childrenrsquos Medical Services Florida Department of Health Available at httphctransitionsichpufledupdfsenvisioning_my_futurepdf
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Morning
Afternoon
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Evening
Night
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
201 W Preston Street ndash Baltimore Maryland 21201 Toll Free 1-877-4MD-DHMH ndash TTYMaryland Relay Service 1-800-735-2258
Web Site wwwdhmhmarylandgov
STATE OF MARYLAND
DHMH Maryland Department of Health and Mental Hygiene Larry Hogan Governor - Boyd Rutherford Lt Governor - Van Mitchell Secretary
Dear Parents and Caregivers This care notebook has been designed for you the parents and caregivers of a child with special health care needs You play an important role in your childrsquos care and doctors and nurses rely on you to give them information about your childrsquos health It is helpful to have all your childrsquos health care information organized and in one place so you can manage it easily Please use this health care notebook to adapt it to fit your childrsquos needs (see Creating Your Care Notebook on the next page) The Office for Genetics and People with Special Health Care Needs is also a resource for locating information on services you may need for your child Please call our Special Health Care Needs Resource Line on 410-767-1063 or 1-800-638-8864 for help You can also log on to our Resource Locator website httpspecialneedsdhmhmarylandgov to locate resources for children and youth with special needs If you have any questions please contact our parent resource coordinator Ms Angela Sitter at the above number She will be happy to assist you Regards
Donna X Harris Director Office for Genetics and People with Special Health Care Needs
Disclaimer This Patient Care Notebook is intended to assist you in maintaining and organizing your childrsquos medical record information You should take the Notebook to your childrsquos medical appointments and emergency visits to assist you in providing the necessary medical information to your childrsquos medical provider and to update information from the current doctor visit Please keep the Patient Care Notebook in a safe location The State of Maryland will not be responsible for loss or misplaced Patient Care Notebooks
The Youth2YoungAdult Care Notebook is adapted from the Teen Care Notebook created by Seattle Washington Hospital Research Foundation The Center for Child with Special Needs copy
2001 ‐ 2013 Seattle Childrens | All Rights Reserved
Are you a young person with a health condition that is beginning to take a more active role in your own health
The Youth2YoungAdult Care Notebook is a great way to organize information about your health
condition and treatments in one place You can also use it to share information with your parents
doctors nurses and other health care professionals
You can use the Youth2YoungAdult Care Notebook to
Track changes in your medicines or treatments
List phone numbers for health care providers and community organizations
Prepare for appointments
File information about your health history
Share new information with your primary doctor nurse and others
To set up your Youth2YoungAdult Care Notebook
Step 1 Gather your existing information Gather up any health information you and your parents
already have This may include reports from recent doctorrsquos visits immunization records recent
summary of a hospital stay this yearrsquos school plan test results or informational pamphlets
Step 2 Review the Care Notebook Which of these pages may help you keep track of information
about your health or care Choose the pages you like You can either print copies of any that you
think you will use and fill them out by hand or download a copy and save it to your computer so that
you can easily update the pages in the future
Step 3 Choose what to keep in the Care Notebook Decide what information you look up most
often and what information is needed by others Store other information in a file drawer or box where
you can find it if needed
Step 4 Assemble your Care Notebook The key is to make it easy for you to find the information
you need quickly and easily Some ideas in putting your Care Notebook together include using a 3-
ring binder with tabbed dividers to create your own sections pocket dividers to store reports andor
plastic pages to store business cards and photographs Or get an expandable folder if you are a
stuffer
Youth2YoungAdult Care Notebook Table of Contents
Keep Track of Your Contacts
Hospital Information List
MedicalDental Care Providers List
Home Care Providers List
Therapists List
Pharmacy List
Special Transportation List
Teen Family Information List
InsuranceFunding Sources List
Keep Track of Appointments and Care
Care Schedule
Appointment Log
MedicalSurgical Highlights
Lab WorkTestsProcedures List
Equipment and Supplies List
Medications List
Diet Tracking Form
Hospital Stay Tracking Form
Medical Bill Tracking
Make a Calendar
Notes
Document Your Care Plan
Getting to Know Me
Whats the Plan
Emergency Information Card
iTransition-Health Online Resources
Health Care Transition Resources for Youth
Health Care Transition Resources for Parents Families and Caregivers
Health Care Transition Resources for Providers
Health Care Transition Resources for Educators
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Family Information
Your Name Nickname Date of Birth Diagnosis Blood Type
Legal Guardian Address Phone
Family Members
Motherrsquos Name Address Email Daytime Phone Evening Phone Cell
Fatherrsquos Name Address Email Daytime Phone Evening Phone Cell
Siblingrsquos Name Age Name Age Name Age Name Age
Other Household Members
Important Family Information Language Spoken at Home Other Language(s) Interpreter Needed Yes No Interpreter Phone
Emergency Contact
Name Address Email Daytime Phone Evening Phone Cell
iTransition-Health Resources for Youth and Young Adults Check Your Skills
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Source Envisioning My Future A Young Personrsquos Guide to Health Care Transition from Childrenrsquos Medical Services Florida Department of Health Available at httphctransitionsichpufledupdfsenvisioning_my_futurepdf
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Morning
Afternoon
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Evening
Night
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
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Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
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Insurance Company 1 Address (InsuranceFunding Sources)
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Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
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Supplemental Security Income (InsuranceFunding Sources)
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Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
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Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
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Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
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Insurance Paid 2 (Medical Bill)
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Family Owes 2 (Medical Bill)
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Cost 3 (Medical Bill)
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Family Owes 3 (Medical Bill)
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Cost 4 (Medical Bill)
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Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
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Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
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Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
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Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
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Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
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Home Nursing Agency 1 Phone (Home Care Providers)
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Home Nursing Agency 1 Website (Home Care Providers)
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Home Nursing Agency 2 Start Date (Home Care Providers)
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Home Nursing Agency 2 Address (Home Care Providers)
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Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
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Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
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Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
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Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
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Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
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Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
The Youth2YoungAdult Care Notebook is adapted from the Teen Care Notebook created by Seattle Washington Hospital Research Foundation The Center for Child with Special Needs copy
2001 ‐ 2013 Seattle Childrens | All Rights Reserved
Are you a young person with a health condition that is beginning to take a more active role in your own health
The Youth2YoungAdult Care Notebook is a great way to organize information about your health
condition and treatments in one place You can also use it to share information with your parents
doctors nurses and other health care professionals
You can use the Youth2YoungAdult Care Notebook to
Track changes in your medicines or treatments
List phone numbers for health care providers and community organizations
Prepare for appointments
File information about your health history
Share new information with your primary doctor nurse and others
To set up your Youth2YoungAdult Care Notebook
Step 1 Gather your existing information Gather up any health information you and your parents
already have This may include reports from recent doctorrsquos visits immunization records recent
summary of a hospital stay this yearrsquos school plan test results or informational pamphlets
Step 2 Review the Care Notebook Which of these pages may help you keep track of information
about your health or care Choose the pages you like You can either print copies of any that you
think you will use and fill them out by hand or download a copy and save it to your computer so that
you can easily update the pages in the future
Step 3 Choose what to keep in the Care Notebook Decide what information you look up most
often and what information is needed by others Store other information in a file drawer or box where
you can find it if needed
Step 4 Assemble your Care Notebook The key is to make it easy for you to find the information
you need quickly and easily Some ideas in putting your Care Notebook together include using a 3-
ring binder with tabbed dividers to create your own sections pocket dividers to store reports andor
plastic pages to store business cards and photographs Or get an expandable folder if you are a
stuffer
Youth2YoungAdult Care Notebook Table of Contents
Keep Track of Your Contacts
Hospital Information List
MedicalDental Care Providers List
Home Care Providers List
Therapists List
Pharmacy List
Special Transportation List
Teen Family Information List
InsuranceFunding Sources List
Keep Track of Appointments and Care
Care Schedule
Appointment Log
MedicalSurgical Highlights
Lab WorkTestsProcedures List
Equipment and Supplies List
Medications List
Diet Tracking Form
Hospital Stay Tracking Form
Medical Bill Tracking
Make a Calendar
Notes
Document Your Care Plan
Getting to Know Me
Whats the Plan
Emergency Information Card
iTransition-Health Online Resources
Health Care Transition Resources for Youth
Health Care Transition Resources for Parents Families and Caregivers
Health Care Transition Resources for Providers
Health Care Transition Resources for Educators
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Family Information
Your Name Nickname Date of Birth Diagnosis Blood Type
Legal Guardian Address Phone
Family Members
Motherrsquos Name Address Email Daytime Phone Evening Phone Cell
Fatherrsquos Name Address Email Daytime Phone Evening Phone Cell
Siblingrsquos Name Age Name Age Name Age Name Age
Other Household Members
Important Family Information Language Spoken at Home Other Language(s) Interpreter Needed Yes No Interpreter Phone
Emergency Contact
Name Address Email Daytime Phone Evening Phone Cell
iTransition-Health Resources for Youth and Young Adults Check Your Skills
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Source Envisioning My Future A Young Personrsquos Guide to Health Care Transition from Childrenrsquos Medical Services Florida Department of Health Available at httphctransitionsichpufledupdfsenvisioning_my_futurepdf
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Morning
Afternoon
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Evening
Night
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
Youth2YoungAdult Care Notebook Table of Contents
Keep Track of Your Contacts
Hospital Information List
MedicalDental Care Providers List
Home Care Providers List
Therapists List
Pharmacy List
Special Transportation List
Teen Family Information List
InsuranceFunding Sources List
Keep Track of Appointments and Care
Care Schedule
Appointment Log
MedicalSurgical Highlights
Lab WorkTestsProcedures List
Equipment and Supplies List
Medications List
Diet Tracking Form
Hospital Stay Tracking Form
Medical Bill Tracking
Make a Calendar
Notes
Document Your Care Plan
Getting to Know Me
Whats the Plan
Emergency Information Card
iTransition-Health Online Resources
Health Care Transition Resources for Youth
Health Care Transition Resources for Parents Families and Caregivers
Health Care Transition Resources for Providers
Health Care Transition Resources for Educators
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Family Information
Your Name Nickname Date of Birth Diagnosis Blood Type
Legal Guardian Address Phone
Family Members
Motherrsquos Name Address Email Daytime Phone Evening Phone Cell
Fatherrsquos Name Address Email Daytime Phone Evening Phone Cell
Siblingrsquos Name Age Name Age Name Age Name Age
Other Household Members
Important Family Information Language Spoken at Home Other Language(s) Interpreter Needed Yes No Interpreter Phone
Emergency Contact
Name Address Email Daytime Phone Evening Phone Cell
iTransition-Health Resources for Youth and Young Adults Check Your Skills
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Source Envisioning My Future A Young Personrsquos Guide to Health Care Transition from Childrenrsquos Medical Services Florida Department of Health Available at httphctransitionsichpufledupdfsenvisioning_my_futurepdf
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Morning
Afternoon
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Evening
Night
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
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Appointment 3 Provider Info (Appt Log)
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Appointment 4 Provider Info (Appt Log)
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Next Appt 4 (Appt Log)
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Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
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Appointment 6 Provider Info (Appt Log)
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Next Appt 6 (Appt Log)
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Appointment 7 Provider Info (Appt Log)
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Appointment 8 Provider Info (Appt Log)
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Next Appt 8 (Appt Log)
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Appointment 9 Provider Info (Appt Log)
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Next Appt 9 (Appt Log)
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Appointment 10 Provider Info (Appt Log)
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Next Appt 10 (Appt Log)
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Appointment 11 Provider Info (Appt Log)
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Next Appt 11 (Appt Log)
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Next Appt 12 (Appt Log)
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Appointment 13 Provider Info (Appt Log)
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Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
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Date Started 1 (Medication Form)
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Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
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Date 8 (Procedures)
Procedure 8 (Procedures)
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Date 9 (Procedures)
Procedure 9 (Procedures)
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Procedure 12 (Procedures)
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Procedure 14 (Procedures)
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Procedure 15 (Procedures)
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Comments 19 (Procedures)
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Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
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Date 5 (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Family Information
Your Name Nickname Date of Birth Diagnosis Blood Type
Legal Guardian Address Phone
Family Members
Motherrsquos Name Address Email Daytime Phone Evening Phone Cell
Fatherrsquos Name Address Email Daytime Phone Evening Phone Cell
Siblingrsquos Name Age Name Age Name Age Name Age
Other Household Members
Important Family Information Language Spoken at Home Other Language(s) Interpreter Needed Yes No Interpreter Phone
Emergency Contact
Name Address Email Daytime Phone Evening Phone Cell
iTransition-Health Resources for Youth and Young Adults Check Your Skills
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Source Envisioning My Future A Young Personrsquos Guide to Health Care Transition from Childrenrsquos Medical Services Florida Department of Health Available at httphctransitionsichpufledupdfsenvisioning_my_futurepdf
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Morning
Afternoon
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Evening
Night
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
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Date 5 (Calendar)
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Date 6 (Calendar)
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Date 7 (Calendar)
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Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
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Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
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Date 12 (Calendar)
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Date 13 (Calendar)
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Date 14 (Calendar)
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Date 15 (Calendar)
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Date Text 21 (Calendar)
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Text (Notes)
iTransition-Health Resources for Youth and Young Adults Check Your Skills
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Source Envisioning My Future A Young Personrsquos Guide to Health Care Transition from Childrenrsquos Medical Services Florida Department of Health Available at httphctransitionsichpufledupdfsenvisioning_my_futurepdf
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Morning
Afternoon
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Evening
Night
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
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Date 10 (Calendar)
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Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
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Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
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Date Text 17 (Calendar)
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Date 19 (Calendar)
Date Text 19 (Calendar)
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Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Morning
Afternoon
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Evening
Night
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Care Schedule
TIME CARE
Evening
Night
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
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Date Text 27 (Calendar)
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Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Diet Tracking Form
DATE SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
Tube Feeding
Breakfast
Lunch
Dinner
Snacks
Notes
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Dental Community Health Care Providers
Primary Community Care Provider
Office Nurse
Address
Phone Fax Email
Website
Community Hospital
Medical Record Number
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Community Specialty Care Provider
Address
Phone Fax Email
Website
Dentist Orthodontist
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
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Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
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Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
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Test 17 (Lab Work)
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Test 18 (Lab Work)
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Test 19 (Lab Work)
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Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
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Comments 4 (Procedures)
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Procedure 5 (Procedures)
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Comments 5 (Procedures)
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Procedure 6 (Procedures)
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Comments 6 (Procedures)
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Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
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Procedure 11 (Procedures)
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Comments 11 (Procedures)
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Procedure 12 (Procedures)
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Comments 12 (Procedures)
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Procedure 13 (Procedures)
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Comments 13 (Procedures)
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Procedure 14 (Procedures)
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Procedure 15 (Procedures)
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Comments 15 (Procedures)
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Procedure 16 (Procedures)
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Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
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Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
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Date 12 (Calendar)
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Date Text 14 (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Pharmacy Community Health Care Service Providers
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
Pharmacy HoursDays of Operation
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Therapists Community Health Care Service Providers
Therapists
Occupational Therapist (OT)
Start Date
Agency
Address
Phone Fax Email
Physical Therapist (PT)
Start Date
Agency
Address
Phone Fax Email
Speech-Language Pathologist
Start Date
Agency
Address
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
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Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
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Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
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Insurance Company 2 Policy Number (InsuranceFunding Sources)
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Supplemental Security Income (InsuranceFunding Sources)
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Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
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Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
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Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
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Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
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Family Owes 2 (Medical Bill)
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Date 3 (Medical Bill)
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Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
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Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
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Home Nursing Agency 1 Website (Home Care Providers)
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Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
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Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
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Home Nursing Agency 3 Start Date (Home Care Providers)
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Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
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Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
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Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
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Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
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Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
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Procedure 7 (Procedures)
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Comments 7 (Procedures)
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Procedure 8 (Procedures)
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Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
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Comments 9 (Procedures)
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Procedure 10 (Procedures)
Results 10 (Procedures)
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Procedure 11 (Procedures)
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Procedure 12 (Procedures)
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Comments 12 (Procedures)
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Procedure 13 (Procedures)
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Comments 13 (Procedures)
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Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
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Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
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Procedure 16 (Procedures)
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Comments 16 (Procedures)
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Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
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Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
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Date 6 (Calendar)
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Date 8 (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Appointment Log
DATE PROVIDER REASON FOR APPOINTMENT CARE PROVIDED
NEXT APPOINTMENT
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
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Date Text 17 (Calendar)
Date 18 (Calendar)
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Date 19 (Calendar)
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Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
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Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
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Date 32 (Calendar)
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Date 33 (Calendar)
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Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Insurance Company
Policy Number
Contact Person Title
Address
Phone Fax Email
Website
Supplemental Security Income (SSI)
Contact Person Title
Address
Phone Fax Email
Website
(continued)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
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Physical Therapist Address (Therapists)
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Physical Therapist Fax (Therapists)
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Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
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Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
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Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
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Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
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Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
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Cost 3 (Medical Bill)
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Provider 4 (Medical Bill)
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Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
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Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
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Medication 10 (Medication Form)
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Medication 11 (Medication Form)
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Medication 12 (Medication Form)
Date Started 12 (Medication Form)
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Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
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Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
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Date 4 (Hospital Stay)
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Date 5 (Hospital Stay)
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Date 6 (Hospital Stay)
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Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
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Hospital 13 (Hospital Stay)
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Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
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Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
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Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
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Procedure 3 (Procedures)
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Procedure 4 (Procedures)
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Procedure 7 (Procedures)
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Procedure 8 (Procedures)
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Comments 8 (Procedures)
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Procedure 9 (Procedures)
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Procedure 10 (Procedures)
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Procedure 11 (Procedures)
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Procedure 12 (Procedures)
Results 12 (Procedures)
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Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
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Procedure 14 (Procedures)
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Comments 14 (Procedures)
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Procedure 15 (Procedures)
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Procedure 16 (Procedures)
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Procedure 17 (Procedures)
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Procedure 18 (Procedures)
Results 18 (Procedures)
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Procedure 19 (Procedures)
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Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
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Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
InsuranceFunding Sources
Other
Contact PersonTitle
Address
Phone Fax Email
Website
Other
Contact PersonTitle
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
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Primary Care Provider Fax (MedicalDental Care List)
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Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
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Community Specialty Care Provider 1 (MedicalDental Care List)
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Community Specialty Care Provider1 Email (MedicalDental Care List)
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Community Specialty Care Provider 2 Fax (MedicalDental Care List)
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DentistOrthodontist (MedicalDental Care List)
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DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
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Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
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Procedure 4 (Procedures)
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Comments 4 (Procedures)
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Procedure 5 (Procedures)
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Comments 5 (Procedures)
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Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
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Procedure 7 (Procedures)
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Comments 7 (Procedures)
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Procedure 8 (Procedures)
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Comments 8 (Procedures)
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Procedure 9 (Procedures)
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Comments 9 (Procedures)
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Procedure 10 (Procedures)
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Procedure 11 (Procedures)
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Procedure 12 (Procedures)
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Comments 12 (Procedures)
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Procedure 13 (Procedures)
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Comments 13 (Procedures)
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Procedure 14 (Procedures)
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Comments 14 (Procedures)
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Procedure 15 (Procedures)
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Procedure 16 (Procedures)
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Procedure 17 (Procedures)
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Comments 17 (Procedures)
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Procedure 18 (Procedures)
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Comments 18 (Procedures)
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Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
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Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
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Date 3 (Calendar)
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Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
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Date 6 (Calendar)
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Date Text 14 (Calendar)
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Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Bill Tracking Form
DATE PROVIDER COST INSURANCE PAID
DATE PAID FAMILY OWES DATE PAID
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Home Care Community Health Care Service Providers
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
Home Nursing Agency
Start Date
Contact Person
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
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Community Hospital Fax (MedicalDental Care List)
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Community Specialty Care Provider 1 (MedicalDental Care List)
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Community Specialty Care Provider 1 Fax (MedicalDental Care List)
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DentistOrthodontist (MedicalDental Care List)
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Pharmacy 1 (Pharmacy List)
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Speech-Language Pathologist (Therapists)
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Appt 1 Date (Appt Log)
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Insurance Company 1 (InsuranceFunding Sources)
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Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
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Insurance Company 2 Fax (InsuranceFunding Sources)
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Supplemental Security Income (InsuranceFunding Sources)
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Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
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Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
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Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
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Family Owes 2 (Medical Bill)
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Date 3 (Medical Bill)
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Cost 3 (Medical Bill)
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Family Owes 3 (Medical Bill)
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Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
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Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
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Family Owes 5 (Medical Bill)
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Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
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Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
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Family Owes 7 (Medical Bill)
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Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
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Family Owes 8 (Medical Bill)
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Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
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Family Owes 10 (Medical Bill)
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Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
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Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
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Insurance Paid 13 (Medical Bill)
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Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
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Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
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Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
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Contact Person 1 (Special Transportation)
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Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
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Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
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Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
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Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
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Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
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Clinic 2 Hours Days of Operation (Hospital Name)
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Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
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Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
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Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
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Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
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Comments 9 (Lab Work)
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Test 10 (Lab Work)
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Test 11 (Lab Work)
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Test 12 (Lab Work)
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Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
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Procedure 3 (Procedures)
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Procedure 4 (Procedures)
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Procedure 5 (Procedures)
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Procedure 6 (Procedures)
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Procedure 8 (Procedures)
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Procedure 9 (Procedures)
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Procedure 10 (Procedures)
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Procedure 11 (Procedures)
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Procedure 12 (Procedures)
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Procedure 13 (Procedures)
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Procedure 14 (Procedures)
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Comments 14 (Procedures)
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Procedure 15 (Procedures)
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Comments 15 (Procedures)
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Procedure 16 (Procedures)
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Comments 16 (Procedures)
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Procedure 17 (Procedures)
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Comments 17 (Procedures)
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Procedure 18 (Procedures)
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Comments 18 (Procedures)
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Procedure 19 (Procedures)
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Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medications
Allergies
Pharmacy Phone
MEDICATION DATE
STARTED DATE
STOPPED
DOSE ROUTE (with or without
food) TIME GIVEN PRESCRIBED BY
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
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Test 18 (Lab Work)
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Comments 18 (Lab Work)
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Test 19 (Lab Work)
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Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
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Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
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Comments 4 (Procedures)
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Procedure 5 (Procedures)
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Comments 5 (Procedures)
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Procedure 6 (Procedures)
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Procedure 7 (Procedures)
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Comments 7 (Procedures)
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Procedure 8 (Procedures)
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Date 9 (Procedures)
Procedure 9 (Procedures)
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Date 10 (Procedures)
Procedure 10 (Procedures)
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Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
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Procedure 12 (Procedures)
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Procedure 14 (Procedures)
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Procedure 15 (Procedures)
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Procedure 16 (Procedures)
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Procedure 17 (Procedures)
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Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
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Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Special Transportation Community Health Care Service Providers
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
Transportation (to and from medical therapy appointments)
Contact Person
Agency
Address
Phone Fax Email
Website
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Equipment Supplies
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Name of Equipment
Description (brand name model size etc)
Date obtained Supplier
Website
Contact Person Phone
Serial Number
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
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Next Appt 2 (Appt Log)
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Next Appt 5 (Appt Log)
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Next Appt 9 (Appt Log)
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Next Appt 10 (Appt Log)
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Next Appt 12 (Appt Log)
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Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
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Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
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Phone 2 (EquipmentSupplies)
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Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
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Supplier 3 (EquipmentSupplies)
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Description 4 (EquipmentSupplies)
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Supplier 4 (EquipmentSupplies)
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Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
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Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
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Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
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Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
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Hospital 3 (Hospital Stay)
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Hospital 9 (Hospital Stay)
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Hospital 14 (Hospital Stay)
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Notes 14 (Hospital Stay)
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Test 1 (Lab Work)
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Text (Notes)
Care Plans for Teens
httpcshcnorgprint104[9302011 105615 AM]
Care Plans for TeensWhat is a care plan
A care plan is written information about how to best care for your own healthneeds It is a way for you to know about understand and participate in yourcare It is something you and your parents or doctor can make together
A care plan may include
What medicines you take and whenWhat foods you should avoidHow often you get physical therapyWhat others should do if you havean emergency
How can a care plan help me
Care plans can help you be active in yourown care They help you get informationabout your condition and understand yourhealth history They also help you prepare for spending time away from home or for emergency situations
A teen with diabetes explains
ldquoManaging my health condition can be complicated There are so many parts to keep track of and I can getoverwhelmed Creating and filling out a care plan really helps me focus on what questions I need to beasking and what things I need to be thinking about It allows me to take on more responsibility for my ownhealth I print out copies of my care plan and make a list of people I should share it with It makes talkingto them much easier and I dont forget anything My swim coach friends and teachers really appreciate itrdquo
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
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DentistOrthodontist (MedicalDental Care List)
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Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
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Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
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Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
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Speech-Language Pathologist (Therapists)
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Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
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Appointment 1 Reason Seen Care Provided (Appt Log)
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Next Appt 16 (Appt Log)
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Next Appt 17 (Appt Log)
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Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
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Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Name Address
City State Zip Code Website
Phone Numbers
Main Number Emergency Room
Medical Record Number
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
Clinic __________________________________ HoursDays of Operation
Physician
Contact Person Title
Phone Fax Email
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Hospital Stay Tracking Form
DATE HOSPITAL REASON NOTES
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
Date Text 22 (Calendar)
Date 23 (Calendar)
Date Text 23 (Calendar)
Date 24 (Calendar)
Date Text 24 (Calendar)
Date 25 (Calendar)
Date Text 25 (Calendar)
Date 26 (Calendar)
Date Text 26 (Calendar)
Date 27 (Calendar)
Date Text 27 (Calendar)
Date 28 (Calendar)
Date Text 28 (Calendar)
Date 29 (Calendar)
Date Text 29 (Calendar)
Date 30 (Calendar)
Date Text 30 (Calendar)
Date 31 (Calendar)
Date Text 31 (Calendar)
Date 32 (Calendar)
Date Text 32 (Calendar)
Date 33 (Calendar)
Date Text 33 (Calendar)
Date 34 (Calendar)
Date Text 34 (Calendar)
Date 35 (Calendar)
Date Text 35 (Calendar)
Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Lab Work Tests Procedures
DATE TEST RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
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Reason 3 (Hospital Stay)
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Hospital 8 (Hospital Stay)
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Notes 8 (Hospital Stay)
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Hospital 9 (Hospital Stay)
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Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
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Hospital 11 (Hospital Stay)
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Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
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Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
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Date 4 (Lab Work)
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Date 1 (Procedures)
Procedure 1 (Procedures)
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Date 2 (Procedures)
Procedure 2 (Procedures)
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Procedure 3 (Procedures)
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Procedure 5 (Procedures)
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Procedure 6 (Procedures)
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Procedure 7 (Procedures)
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Procedure 8 (Procedures)
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Procedure 9 (Procedures)
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Comments 9 (Procedures)
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Procedure 10 (Procedures)
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Procedure 11 (Procedures)
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Date 12 (Procedures)
Procedure 12 (Procedures)
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Procedure 13 (Procedures)
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Comments 13 (Procedures)
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Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
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Date 8 (Calendar)
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Date 9 (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Medical Surgical Procedures
DATE PROCEDURE RESULTS COMMENTS
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
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Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
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Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
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Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
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Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
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Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
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Cost 4 (Medical Bill)
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Family Owes 4 (Medical Bill)
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Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
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Family Owes 5 (Medical Bill)
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Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
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Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
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Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
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Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
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Family Owes 9 (Medical Bill)
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Cost 10 (Medical Bill)
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Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
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Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
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Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
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Dose Route 4 (Medication Form)
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Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
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Dose Route 5 (Medication Form)
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Medication 9 (Medication Form)
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Dose Route 11 (Medication Form)
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Dose Route 12 (Medication Form)
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Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
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Phone 1 (Special Transportation)
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Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
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Notes 3 (Hospital Stay)
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Date 6 (Hospital Stay)
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Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
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Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
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Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
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Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
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Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
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Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
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Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
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Comments 3 (Lab Work)
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Date 1 (Procedures)
Procedure 1 (Procedures)
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Date 2 (Procedures)
Procedure 2 (Procedures)
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Procedure 3 (Procedures)
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Procedure 4 (Procedures)
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Procedure 5 (Procedures)
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Procedure 6 (Procedures)
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Procedure 7 (Procedures)
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Procedure 8 (Procedures)
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Procedure 9 (Procedures)
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Procedure 10 (Procedures)
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Procedure 11 (Procedures)
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Procedure 12 (Procedures)
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Procedure 13 (Procedures)
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Procedure 14 (Procedures)
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Comments 14 (Procedures)
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Procedure 15 (Procedures)
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Comments 15 (Procedures)
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Procedure 16 (Procedures)
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Procedure 17 (Procedures)
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Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
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Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
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Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
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Date 3 (Calendar)
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Text (Notes)
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
Date Text 19 (Calendar)
Date 20 (Calendar)
Date Text 20 (Calendar)
Date 21 (Calendar)
Date Text 21 (Calendar)
Date 22 (Calendar)
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CARE NOTEBOOK Center for Children with Special Needs Seattle Childrens 409 Washington State Department of Health Children with Special Health Care Needs Program
Notes
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
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Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
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Community Specialty Care Provider 2 Fax (MedicalDental Care List)
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Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
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DentistOrthodontist Fax (MedicalDental Care List)
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DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
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Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
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Pharmacy 1 Fax (Pharmacy List)
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Pharmacy 2 Fax (Pharmacy List)
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Physical Therapist Fax (Therapists)
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Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
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Next Appt 19 (Appt Log)
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Next Appt 20 (Appt Log)
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Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
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Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
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Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
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Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
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Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
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Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
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Family Owes 5 (Medical Bill)
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Provider 6 (Medical Bill)
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Insurance Paid 6 (Medical Bill)
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Family Owes 6 (Medical Bill)
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Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
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Family Owes 7 (Medical Bill)
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Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
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Family Owes 8 (Medical Bill)
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Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
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Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
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Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
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Serial Number 2 (EquipmentSupplies)
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Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
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Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
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Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
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Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
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Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
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Date 1 (Hospital Stay)
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Hospital 9 (Hospital Stay)
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Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
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Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
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Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
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Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
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Date 4 (Lab Work)
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Test 5 (Lab Work)
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Test 6 (Lab Work)
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Comments 6 (Lab Work)
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Test 7 (Lab Work)
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Test 8 (Lab Work)
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Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
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Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
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Date 12 (Lab Work)
Test 12 (Lab Work)
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Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
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Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
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Test 15 (Lab Work)
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Comments 15 (Lab Work)
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Test 16 (Lab Work)
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Date 17 (Lab Work)
Test 17 (Lab Work)
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Test 18 (Lab Work)
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Test 20 (Lab Work)
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Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
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Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
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Date 12 (Calendar)
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Text (Notes)
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Health Care Transition Resources for Youth
Youth2YoungAdult Care Notebook httpcshcnorgplanning-record-keepingteen-care-notebook This resource help youth and young adults manage aspects of their own health care It contains pre-made fillable forms
KidsHealth
httpkidshealthorgteenindexjsptracking=T_Home This site educates youth on health basis diseases and conditions
The Youthhood
httpwwwyouthhoodorg ndash This site helps you start thinking about what you want to do with the rest of your life and plan for your future Click on ldquoThe Health Clinicrdquo for resources to help with health issues like doctor visits and health insurance
Got Transition
httpwwwgottransitionorgyouth-information - This is the National Health Care Transition Centerrsquos website and it has resources for youth (mostly links to other websites) They also have a Facebook page and the ldquoGot Transition Radio Showrdquo Click to listen to shows on topics like lsquoBefore a Drs visit From Panic to Preparedrsquo and lsquoHealthcare Transition amp College- It Doesnt Have to be Learned the Hard Wayrsquo
Healthy Transitions
httphealthytransitionsnyorgskills_mediatool_show - This is New York Statersquos website for moving from pediatric to adult health care It has lots of fun and useful tools and ideas to help with health care transition Some of the things are just for New York state residents but a lot of the stuff is good for everyone no matter where you live
My Med Schedule
httpwwwmymedschedulecom - This site helps you create and print medication schedules and to set up text or email reminders for yourself to take your meds and get refills
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
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DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
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Pharmacy 1 Fax (Pharmacy List)
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Pharmacy 2 (Pharmacy List)
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Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
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Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
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Next Appt 2 (Appt Log)
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Next Appt 5 (Appt Log)
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Next Appt 6 (Appt Log)
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Next Appt 8 (Appt Log)
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Next Appt 9 (Appt Log)
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Next Appt 10 (Appt Log)
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Next Appt 11 (Appt Log)
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Next Appt 12 (Appt Log)
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Next Appt 13 (Appt Log)
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Next Appt 14 (Appt Log)
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Next Appt 15 (Appt Log)
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Next Appt 16 (Appt Log)
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Next Appt 17 (Appt Log)
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Next Appt 18 (Appt Log)
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Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
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Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
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Date 11 (Calendar)
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Text (Notes)
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Parents Families and Caregivers
My Health Care Notebook httpfhadhmhmarylandgovgeneticsSitePagescare_notebookaspx - This resource helps parents manage aspects of their child and or youthrsquos health care It contains pre-made fillable forms
Maryland Children and Youth with Special Health Care Needs Resource Locator httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Got Transition httpwwwgottransitionorgfamily-information - This part of the Got Transition website is for families to find and share transition information Families will use this site to plan for health care transition get ready to talk to their childs or young adults pediatrician about health care transition and learn about ways their young adult can help themselves as they go through a health care transition
Maryland Transitioning Youth
httpwwwmdtransitionorg - This site has transition planning resources for employment education health care and transportation for Maryland youth and young adults
Transition to Adult Health Care A Training Guide in Two Parts
httpwwwwaismanwisceduwrcpdfpubsTAHCpdf - This training resource ldquoTransition to Adult Health Care A Training Guide in Two Partsrdquo helps young people with special health care needs and their parents prepare for transition to adult health care Part One is aimed at parents of children with special needs Part Two is aimed at the young people themselves
Emergency Preparedness for People with Disabilities and their Families The Take and Go Emergency Book - httpnewdhhlouisianagovassetsdocsOCDDpublicationsEmergencyPreparednessTheTakeandGoEmergencyBookpdf -This resource is a quick source of information during disasters if families are separated
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
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Next Appt 2 (Appt Log)
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Next Appt 3 (Appt Log)
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Next Appt 4 (Appt Log)
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Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
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Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
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Next Appt 7 (Appt Log)
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Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
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Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
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Text (Notes)
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
Transition Resources for Providers
National Health Care Transition Center Got Transition httpwwwgottransitionorgproviders-best-practices - This portion of the National Health Care Transition Centerrsquos website Got Transition supports health care professionals to implement transition best practices
Maryland Children and Youth with Special Health Care Needs Resource Locator
httpspecialneedsdhmhmarylandgov This is an easy to use online database designed to help families of children with special health care needs youth and providers find needed resources It is accessible in over 50 languages and offers user-friendly features including helpful search features interactive maps and directions to each resource and is 508-compliant for those with visual impairments
Supporting the Health Care Transition from Adolescence to Adulthood in the Medical
Home httpwwwgottransitionorgUploadedFilesFilesHCTClinicalReporteversion27June2011pdf - This clinical reportresource represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it Primary care physicians nurse practitioners and physician assistants as well as medical subspecialists are encouraged to adopt these materials and make this process specific to their settings and populations
Transition Resources for Educators
bull ldquoHealth in the Individualized Education Plan (IEP)rdquo - (httpdeptswashingtoneduhealthtrdocumentsieppdf) -These Washington State resource provides details on the parts of the IEP and how measurable health goals can be included
bull Adolescent Health Transition Project - (httpdeptswashingtoneduhealthtrschooliephtml) - This is a resource involving teens with SHCN schools and providers in transition
bull ldquoTransition Planning for Special Education Students The Role of the School Nurserdquo
(httpdeptswashingtoneduhealthtrdocumentsimportanceofhealthpdf) - This resource provides details steps the school nurses can use for health transition planning
bull
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
PrimaryCommunity Care Provider (MedicalDental Care List)
Primary Care Provider Office Nurse (MedicalDental Care List)
Primary Care Provider Address (MedicalDental Care List)
Primary Care Provider Phone (MedicalDental Care List)
Primary Care Provider Fax (MedicalDental Care List)
Primary Care Provider Email (MedicalDental Care List)
Primary Care Provider Website (MedicalDental Care List)
Community Hospital (MedicalDental Care List)
Medical Record Number (MedicalDental Care List)
Community Hospital Address (MedicalDental Care List)
Community Hospital Phone (MedicalDental Care List)
Community Hospital Fax (MedicalDental Care List)
Community Hospital Email (MedicalDental Care List)
Community Hospital Website (MedicalDental Care List)
Community Specialty Care Provider 1 (MedicalDental Care List)
Community Specialty Care Provider 1 Address (MedicalDental Care List)
Community Specialty Care Provider 1 Phone (MedicalDental Care List)
Community Specialty Care Provider 1 Fax (MedicalDental Care List)
Community Specialty Care Provider1 Email (MedicalDental Care List)
Community Specialty Care Provider 1 Website (MedicalDental Care List)
Community Specialty Care Provider 2 (MedicalDental Care List)
Community Specialty Care Provider 2 Address (MedicalDental Care List)
Community Specialty Care Provider 2 Phone (MedicalDental Care List)
Community Specialty Care Provider 2 Fax (MedicalDental Care List)
Community Specialty Care Provider 2 Email (MedicalDental Care List)
Community Specialty Care Provider 2 Website (MedicalDental Care List)
DentistOrthodontist (MedicalDental Care List)
DentistOrthodontist Address (MedicalDental Care List)
DentistOrthodontist Phone (MedicalDental Care List)
DentistOrthodontist Fax (MedicalDental Care List)
DentistOrthodontist Email (MedicalDental Care List)
DentistOrthodontist Website (MedicalDental Care List)
Pharmacy 1 (Pharmacy List)
Pharmacy 1 Hours Days of Operation (Pharmacy List)
Pharmacy 1 Contact Person (Pharmacy List)
Pharmacy 1 Address (Pharmacy List)
Pharmacy 1 Phone (Pharmacy List)
Pharmacy 1 Fax (Pharmacy List)
Pharmacy 1 Email (Pharmacy List)
Pharmacy 1 Website (Pharmacy List)
Pharmacy 2 (Pharmacy List)
Pharmacy 2 Hours Days of Operation (Pharmacy List)
Pharmacy 2 Contact Person (Pharmacy List)
Pharmacy 2 Address (Pharmacy List)
Pharmacy 2 Phone (Pharmacy List)
Pharmacy 2 Fax (Pharmacy List)
Pharmacy 2 Email (Pharmacy List)
Pharmacy 2 Website (Pharmacy List)
Pharmacy 3 (Pharmacy List)
Pharmacy 3 Hours Days of Operation (Pharmacy List)
Pharmacy 3 Contact Person (Pharmacy List)
Pharmacy 3 Address (Pharmacy List)
Pharmacy 3 Phone (Pharmacy List)
Pharmacy 3 Fax (Pharmacy List)
Pharmacy 3 Email (Pharmacy List)
Pharmacy 3 Website (Pharmacy List)
Occupational Therapist (Therapists)
Occupational Therapist Start Date (Therapists)
Occupational Therapist Agency (Therapists)
Occupational Therapist Address (Therapists)
Occupational Therapist Phone (Therapists)
Occupational Therapist Fax (Therapists)
Occupational Therapist Email (Therapists)
Physical Therapist (Therapists)
Physical Therapist Start Date (Therapists)
Physical Therapist Agency (Therapists)
Physical Therapist Address (Therapists)
Physical Therapist Phone (Therapists)
Physical Therapist Fax (Therapists)
Physical Therapist Email (Therapists)
Speech-Language Pathologist (Therapists)
Speech-Language Pathologist Start Date (Therapists)
Speech-Language Pathologist Agency (Therapists)
Speech-Language Pathologist Address (Therapists)
Speech-Language Pathologist Phone (Therapists)
Speech-Language Pathologist Fax (Therapists)
Speech-Language Pathologist Email (Therapists)
Appt 1 Date (Appt Log)
Appointment 1 Provider Info (Appt Log)
Appointment 1 Reason Seen Care Provided (Appt Log)
Next Appt 1 (Appt Log)
Appt 2 Date (Appt Log)
Appointment 2 Provider Info (Appt Log)
Appointment 2 Reason Seen Care Provided (Appt Log)
Next Appt 2 (Appt Log)
Appt 3 Date (Appt Log)
Appointment 3 Provider Info (Appt Log)
Appointment 3 Reason Seen Care Provided (Appt Log)
Next Appt 3 (Appt Log)
Appt 4 Date (Appt Log)
Appointment 4 Provider Info (Appt Log)
Appointment 4 Reason Seen Care Provided (Appt Log)
Next Appt 4 (Appt Log)
Appt 5 Date (Appt Log)
Appointment 5 Provider Info (Appt Log)
Appointment 5 Reason Seen Care Provided (Appt Log)
Next Appt 5 (Appt Log)
Apt 6 Date (Appt Log)
Appointment 6 Provider Info (Appt Log)
Appointment 6 Reason Seen Care Provided (Appt Log)
Next Appt 6 (Appt Log)
Appt 7 Date (Appt Log)
Appointment 7 Provider Info (Appt Log)
Appointment 7 Reason Seen Care Provided (Appt Log)
Next Appt 7 (Appt Log)
Appt 8 Date (Appt Log)
Appointment 8 Provider Info (Appt Log)
Appointment 8 Reason Seen Care Provided (Appt Log)
Next Appt 8 (Appt Log)
Appt 9 Date (Appt Log)
Appointment 9 Provider Info (Appt Log)
Appointment 9 Reason Seen Care Provided (Appt Log)
Next Appt 9 (Appt Log)
Appt 10 Date (Appt Log)
Appointment 10 Provider Info (Appt Log)
Appointment 10 Reason Seen Care Provided (Appt Log)
Next Appt 10 (Appt Log)
Appt 11 Date (Appt Log)
Appointment 11 Provider Info (Appt Log)
Appointment 11 Reason Seen Care Provided (Appt Log)
Next Appt 11 (Appt Log)
Appt 12 Date (Appt Log)
Appointment 12 Provider Info (Appt Log)
Appointment 12 Reason Seen Care Provided (Appt Log)
Next Appt 12 (Appt Log)
Appt 13 Date (Appt Log)
Appointment 13 Provider Info (Appt Log)
Appointment 13 Reason Seen Care Provided (Appt Log)
Next Appt 13 (Appt Log)
Appt 14 Date (Appt Log)
Appointment 14 Provider Info (Appt Log)
Appointment 14 Reason Seen Care Provided (Appt Log)
Next Appt 14 (Appt Log)
Appt 15 Date (Appt Log)
Appointment 15 Provider Info (Appt Log)
Appointment 15 Reason Seen Care Provided (Appt Log)
Next Appt 15 (Appt Log)
Appt 16 Date (Appt Log)
Appointment 16 Provider Info (Appt Log)
Appointment 16 Reason Seen Care Provided (Appt Log)
Next Appt 16 (Appt Log)
Appt 17 Date (Appt Log)
Appointment 17 Provider Info (Appt Log)
Appointment 17 Reason Seen Care Provided (Appt Log)
Next Appt 17 (Appt Log)
Appt 18 Date (Appt Log)
Appointment 18 Provider Info (Appt Log)
Appointment 18 Reason Seen Care Provided (Appt Log)
Next Appt 18 (Appt Log)
Appt 19 Date (Appt Log)
Appointment 19 Provider Info (Appt Log)
Appointment 19 Reason Seen Care Provided (Appt Log)
Next Appt 19 (Appt Log)
Appt 20 Date (Appt Log)
Appointment 20 Provider Info (Appt Log)
Appointment 20 Reason Seen Care Provided (Appt Log)
Next Appt 20 (Appt Log)
Appt 21 Date (Appt Log)
Appointment 21 Provider Info (Appt Log)
Appointment 21 Reason Seen Care Provided (Appt Log)
Next Appt 21 (Appt Log)
Insurance Company 1 (InsuranceFunding Sources)
Insurance Company 1 Policy Number (InsuranceFunding Sources)
Insurance Company 1 Contact Person Title (InsuranceFunding Sources)
Insurance Company 1 Address (InsuranceFunding Sources)
Insurance Company 1 Phone (InsuranceFunding Sources)
Insurance Company 1 Fax (InsuranceFunding Sources)
Insurance Company 1 Email (InsuranceFunding Sources)
Insurance Company 1 Website (InsuranceFunding Sources)
Insurance Company 2 (InsuranceFunding Sources)
Insurance Company 2 Policy Number (InsuranceFunding Sources)
Insurance Company 2 Contact Person Title (InsuranceFunding Sources)
Insurance Company 2 Address (InsuranceFunding Sources)
Insurance Company 2 Phone (InsuranceFunding Sources)
Insurance Company 2 Fax (InsuranceFunding Sources)
Insurance Company 2 Email (InsuranceFunding Sources)
Insurance Company 2 Website (InsuranceFunding Sources)
Insurance Company 3 (InsuranceFunding Sources)
Insurance Company 3 Policy Number (InsuranceFunding Sources)
Insurance Company 3 Contact Person Title (InsuranceFunding Sources)
Insurance Company 3 Address (InsuranceFunding Sources)
Insurance Company 3 Phone (InsuranceFunding Sources)
Insurance Company 3 Fax (InsuranceFunding Sources)
Insurance Company 3 Email (InsuranceFunding Sources)
Insurance Company 3 Website (InsuranceFunding Sources)
Supplemental Security Income (InsuranceFunding Sources)
Supplemental Security Income Contact Person Title (InsuranceFunding Sources)
Supplemental Security Income Address (InsuranceFunding Sources)
Supplemental Security Income Phone (InsuranceFunding Sources)
Supplemental Security Income Fax (InsuranceFunding Sources)
Supplemental Security Income Email
Supplemental Security Income Website
Other 1 (InsuranceFunding Sources)
Other 1 Contact Person Title (InsuranceFunding Sources)
Other 1 Address (InsuranceFunding Sources)
Other 1 Phone (InsuranceFunding Sources)
Other 1 Fax (InsuranceFunding Sources)
Other 1 Email (InsuranceFunding Sources)
Other 1 Website (InsuranceFunding Sources)
Other 2 (InsuranceFunding Sources)
Other 2 Contact Person Title (InsuranceFunding Sources)
Other 2 Address (InsuranceFunding Sources)
Other 2 Phone (InsuranceFunding Sources)
Other 2 Fax (InsuranceFunding Sources)
Other 2 Email (InsuranceFunding Sources)
Other 2 Website (InsuranceFunding Sources)
Date 1 (Medical Bill)
Provider 1 (Medical Bill)
Cost 1 (Medical Bill)
Insurance Paid 1 (Medical Bill)
Insurance Date Paid 1 (Medical Bill)
Family Owes 1 (Medical Bill)
Family Owes Date Paid 1 (Medical Bill)
Date 2 (Medical Bill)
Provider 2 (Medical Bill)
Cost 2 (Medical Bill)
Insurance Paid 2 (Medical Bill)
Insurance Date Paid 2 (Medical Bill)
Family Owes 2 (Medical Bill)
Family Owes Date Paid 2 (Medical Bill)
Date 3 (Medical Bill)
Provider 3 (Medical Bill)
Cost 3 (Medical Bill)
Insurance Paid 3 (Medical Bill)
Insurance Date Paid 3 (Medical Bill)
Family Owes 3 (Medical Bill)
Family Owes Date Paid 3 (Medical Bill)
Date 4 (Medical Bill)
Provider 4 (Medical Bill)
Cost 4 (Medical Bill)
Insurance Paid 4 (Medical Bill)
Insurance Date Paid 4 (Medical Bill)
Family Owes 4 (Medical Bill)
Family Owes Date Paid 4 (Medical Bill)
Date 5 (Medical Bill)
Provider 5 (Medical Bill)
Cost 5 (Medical Bill)
Insurance Paid 5 (Medical Bill)
Insurance Date Paid 5 (Medical Bill)
Family Owes 5 (Medical Bill)
Family Owes Date Paid 5 (Medical Bill)
Date 6 (Medical Bill)
Provider 6 (Medical Bill)
Cost 6 (Medical Bill)
Insurance Paid 6 (Medical Bill)
Insurance Date Paid 6 (Medical Bill)
Family Owes 6 (Medical Bill)
Family Owes Date Paid 6 (Medical Bill)
Date 7 (Medical Bill)
Provider 7 (Medical Bill)
Cost 7 (Medical Bill)
Insurance Paid 7 (Medical Bill)
Insurance Date Paid 7 (Medical Bill)
Family Owes 7 (Medical Bill)
Family Owes Date Paid 7 (Medical Bill)
Date 8 (Medical Bill)
Provider 8 (Medical Bill)
Cost 8 (Medical Bill)
Insurance Paid 8 (Medical Bill)
Insurance Date Paid 8 (Medical Bill)
Family Owes 8 (Medical Bill)
Family Owes Date Paid 8 (Medical Bill)
Date 9 (Medical Bill)
Provider 9 (Medical Bill)
Cost 9 (Medical Bill)
Insurance Paid 9 (Medical Bill)
Insurance Date Paid 9 (Medical Bill)
Family Owes 9 (Medical Bill)
Family Owes Date Paid 9 (Medical Bill)
Date 10 (Medical Bill)
Provider 10 (Medical Bill)
Cost 10 (Medical Bill)
Insurance Paid 10 (Medical Bill)
Insurance Date Paid 10 (Medical Bill)
Family Owes 10 (Medical Bill)
Family Owes Date Paid 10 (Medical Bill)
Date 11 (Medical Bill)
Provider 11 (Medical Bill)
Cost 11 (Medical Bill)
Insurance Paid 11 (Medical Bill)
Insurance Date Paid 11 (Medical Bill)
Family Owes 11 (Medical Bill)
Family Owes Date Paid 11 (Medical Bill)
Date 12 (Medical Bill)
Provider 12 (Medical Bill)
Cost 12 (Medical Bill)
Insurance Paid 12 (Medical Bill)
Insurance Date Paid 12 (Medical Bill)
Family Owes 12 (Medical Bill)
Family Owes Date Paid 12 (Medical Bill)
Date 13 (Medical Bill)
Provider 13 (Medical Bill)
Cost 13 (Medical Bill)
Insurance Paid 13 (Medical Bill)
Insurance Date Paid 13 (Medical Bill)
Family Owes 13 (Medical Bill)
Family Owes Date Paid 13 (Medical Bill)
Date 14 (Medical Bill)
Provider 14 (Medical Bill)
Cost 14 (Medical Bill)
Insurance Paid 14 (Medical Bill)
Insurance Date Paid 14 (Medical Bill)
Family Owes 14 (Medical Bill)
Family Owes Date Paid 14 (Medical Bill)
Home Nursing Agency 1 (Home Care Providers)
Home Nursing Agency 1 Start Date (Home Care Providers)
Home Nursing Agency 1 Contact Person (Home Care Providers)
Home Nursing Agency 1 Address (Home Care Providers)
Home Nursing Agency 1 Phone (Home Care Providers)
Home Nursing Agency 1 Fax (Home Care Providers)
Home Nursing Agency 1 Email (Home Care Providers)
Home Nursing Agency 1 Website (Home Care Providers)
Home Nursing Agency 2 (Home Care Providers)
Home Nursing Agency 2 Start Date (Home Care Providers)
Home Nursing Agency 2 Contact Person (Home Care Providers)
Home Nursing Agency 2 Address (Home Care Providers)
Home Nursing Agency 2 Phone (Home Care Providers)
Home Nursing Agency 2 Fax (Home Care Providers)
Home Nursing Agency 2 Email (Home Care Providers)
Home Nursing Agency 2 Website (Home Care Providers)
Home Nursing Agency 3 (Home Care Providers)
Home Nursing Agency 3 Start Date (Home Care Providers)
Home Nursing Agency 3 Contact Person (Home Care Providers)
Home Nursing Agency 3 Address (Home Care Providers)
Home Nursing Agency 3 Phone (Home Care Providers)
Home Nursing Agency 3 Fax (Home Care Providers)
Home Nursing Agency 3 Email (Home Care Providers)
Home Nursing Agency 3 Website (Home Care Providers)
Allergies (Medication Form)
Pharmacy (Medication Form)
Phone (Medication Form)
Medication 1 (Medication Form)
Date Started 1 (Medication Form)
Date Stopped 1 (Medication Form)
Dose Route 1 (Medication Form)
Time Given 1 (Medication Form)
Prescribed By 1 (Medication Form)
Medication 2 (Medication Form)
Date Started 2 (Medication Form)
Date Stopped 2 (Medication Form)
Dose Route 2 (Medication Form)
Time Given 2 (Medication Form)
Prescribed By 2 (Medication Form)
Medication 3 (Medication Form)
Date Started 3 (Medication Form)
Date Stopped 3 (Medication Form)
Dose Route 3 (Medication Form)
Time Given 3 (Medication Form)
Prescribed By 3 (Medication Form)
Medication 4 (Medication Form)
Date Started 4 (Medication Form)
Date Stopped 4 (Medication Form)
Dose Route 4 (Medication Form)
Time Given 4 (Medication Form)
Prescribed By 4 (Medication Form)
Medication 5 (Medication Form)
Date Started 5 (Medication Form)
Date Stopped 5 (Medication Form)
Dose Route 5 (Medication Form)
Time Given 5 (Medication Form)
Prescribed By 5 (Medication Form)
Medication 6 (Medication Form)
Date Started 6 (Medication Form)
Date Stopped 6 (Medication Form)
Dose Route 6 (Medication Form)
Time Given 6 (Medication Form)
Prescribed By 6 (Medication Form)
Medication 7 (Medication Form)
Date Started 7 (Medication Form)
Date Stopped 7 (Medication Form)
Dose Route 7 (Medication Form)
Time Given 7 (Medication Form)
Prescribed By 7 (Medication Form)
Medication 8 (Medication Form)
Date Started 8 (Medication Form)
Date Stopped 8 (Medication Form)
Dose Route 8 (Medication Form)
Time Given 8 (Medication Form)
Prescribed By 8 (Medication Form)
Medication 9 (Medication Form)
Date Started 9 (Medication Form)
Date Stopped 9 (Medication Form)
Dose Route 9 (Medication Form)
Time Given 9 (Medication Form)
Prescribed By 9 (Medication Form)
Medication 10 (Medication Form)
Date Started 10 (Medication Form)
Date Stopped 10 (Medication Form)
Dose Route 10 (Medication Form)
Time Given 10 (Medication Form)
Prescribed By 10 (Medication Form)
Medication 11 (Medication Form)
Date Started 11 (Medication Form)
Date Stopped 11 (Medication Form)
Dose Route 11 (Medication Form)
Time Given 11 (Medication Form)
Prescribed By 11 (Medication Form)
Medication 12 (Medication Form)
Date Started 12 (Medication Form)
Date Stopped 12 (Medication Form)
Dose Route 12 (Medication Form)
Time Given 12 (Medication Form)
Prescribed By 12 (Medication Form)
Contact Person 1 (Special Transportation)
Agency 1 (Special Transportation)
Address 1 (Special Transportation)
Phone 1 (Special Transportation)
Fax 1 (Special Transportation)
Email 1 (Special Transportation)
Website 1 (Special Transportation)
Contact Person 2 (Special Transportation)
Agency 2 (Special Transportation)
Address 2 (Special Transportation)
Phone 2 (Special Transportation)
Fax 2 (Special Transportation)
Email 2 (Special Transportation)
Website Email 2 (Special Transportation)
Name of Equipment 1 (EquipmentSupplies)
Description 1 (EquipmentSupplies)
Date Obtained 1 (EquipmentSupplies)
Supplier 1 (EquipmentSupplies)
Website 1 (EquipmentSupplies)
Contact Person 1 (EquipmentSupplies)
Phone 1 (EquipmentSupplies)
Serial Number 1 (EquipmentSupplies)
Name of Equipment 2 (EquipmentSupplies)
Description 2 (EquipmentSupplies)
Date Obtained 2 (EquipmentSupplies)
Supplier 2 (EquipmentSupplies)
Website 2 (EquipmentSupplies)
Contact Person 2 (EquipmentSupplies)
Phone 2 (EquipmentSupplies)
Serial Number 2 (EquipmentSupplies)
Name of Equipment 3 (EquipmentSupplies)
Description 3 (EquipmentSupplies)
Date Obtained 3 (EquipmentSupplies)
Supplier 3 (EquipmentSupplies)
Website 3 (EquipmentSupplies)
Contact Person 3 (EquipmentSupplies)
Phone 3 (EquipmentSupplies)
Serial Number 3 (EquipmentSupplies)
Name of Equipment 4 (EquipmentSupplies)
Description 4 (EquipmentSupplies)
Date Obtained 4 (EquipmentSupplies)
Supplier 4 (EquipmentSupplies)
Website 4 (EquipmentSupplies)
Contact Person 4 (EquipmentSupplies)
Phone 4 (EquipmentSupplies)
Serial Number 4 (EquipmentSupplies)
Hospital Address (Hospital Name)
Hospital City State Zip (Hospital Name)
Hospital Website (Hospital Name)
Hospital Main Number (Hospital Name)
Hospital ER Phone Number (Hospital Name)
Medical Record Number (Hospital Name)
Clinic Name 1 (Hospital Name)
Clinic 1 Hours Days of Operation (Hospital Name)
Clinic 1 Physician (Hospital Name)
Clinic 1 Contact Person Title (Hospital Name)
Clinic 1 Phone (Hospital Name)
Clinic 1 Fax Number (Hospital Name)
Clinic 1 Email (Hospital Name)
Clinic Name 2 (Hospital Name)
Clinic 2 Hours Days of Operation (Hospital Name)
Clinic 2 Physician (Hospital Name)
Clinic 2 Contact Person Title (Hospital Name)
Clinic 2 Phone (Hospital Name)
Clinic 2 Fax Number (Hospital Name)
Clinic 2 Email (Hospital Name)
Clinic Name 3 (Hospital Name)
Clinic 3 Hours Days of Operation (Hospital Name)
Clinic 3 Physician (Hospital Name)
Clinic 3 Contact Person Title (Hospital Name)
Clinic 3 Phone (Hospital Name)
Clinic 3 Fax Number (Hospital Name)
Clinic 3 Email (Hospital Name)
Date 1 (Hospital Stay)
Hospital 1 (Hospital Stay)
Reason 1 (Hospital Stay)
Notes 1 (Hospital Stay)
Date 2 (Hospital Stay)
Hospital 2 (Hospital Stay)
Reason 2 (Hospital Stay)
Notes 2 (Hospital Stay)
Date 3 (Hospital Stay)
Hospital 3 (Hospital Stay)
Reason 3 (Hospital Stay)
Notes 3 (Hospital Stay)
Date 4 (Hospital Stay)
Hospital 4 (Hospital Stay)
Reason 4 (Hospital Stay)
Notes 4 (Hospital Stay)
Date 5 (Hospital Stay)
Hospital 5 (Hospital Stay)
Reason 5 (Hospital Stay)
Notes 5 (Hospital Stay)
Date 6 (Hospital Stay)
Hospital 6 (Hospital Stay)
Reason 6 (Hospital Stay)
Notes 6 (Hospital Stay)
Date 7 (Hospital Stay)
Hospital 7 (Hospital Stay)
Reason 7 (Hospital Stay)
Notes 7 (Hospital Stay)
Date 8 (Hospital Stay)
Hospital 8 (Hospital Stay)
Reason 8 (Hospital Stay)
Notes 8 (Hospital Stay)
Date 9 (Hospital Stay)
Hospital 9 (Hospital Stay)
Reason 9 (Hospital Stay)
Notes 9 (Hospital Stay)
Date 10 (Hospital Stay)
Hospital 10 (Hospital Stay)
Reason 10 (Hospital Stay)
Notes 10 (Hospital Stay)
Date 11 (Hospital Stay)
Hospital 11 (Hospital Stay)
Reason 11 (Hospital Stay)
Notes 11 (Hospital Stay)
Date 12 (Hospital Stay)
Hospital 12 (Hospital Stay)
Reason 12 (Hospital Stay)
Notes 12 (Hospital Stay)
Date 13 (Hospital Stay)
Hospital 13 (Hospital Stay)
Reason 13 (Hospital Stay)
Notes 13 (Hospital Stay)
Date 14 (Hospital Stay)
Hospital 14 (Hospital Stay)
Reason 14 (Hospital Stay)
Notes 14 (Hospital Stay)
Date 1 (Lab Work)
Test 1 (Lab Work)
Results 1 (Lab Work)
Comments 1 (Lab Work)
Date 2 (Lab Work)
Test 2 (Lab Work)
Results 2 (Lab Work)
Comments 2 (Lab Work)
Date 3 (Lab Work)
Test 3 (Lab Work)
Results 3 (Lab Work)
Comments 3 (Lab Work)
Date 4 (Lab Work)
Test 4 (Lab Work)
Results 4 (Lab Work)
Comments 4 (Lab Work)
Date 5 (Lab Work)
Test 5 (Lab Work)
Results 5 (Lab Work)
Comments 5 (Lab Work)
Date 6 (Lab Work)
Test 6 (Lab Work)
Results 6 (Lab Work)
Comments 6 (Lab Work)
Date 7 (Lab Work)
Test 7 (Lab Work)
Results 7 (Lab Work)
Comments 7 (Lab Work)
Date 8 (Lab Work)
Test 8 (Lab Work)
Results 8 (Lab Work)
Comments 8 (Lab Work)
Date 9 (Lab Work)
Test 9 (Lab Work)
Results 9 (Lab Work)
Comments 9 (Lab Work)
Date 10 (Lab Work)
Test 10 (Lab Work)
Results 10 (Lab Work)
Comments 10 (Lab Work)
Date 11 (Lab Work)
Test 11 (Lab Work)
Results 11 (Lab Work)
Comments 11 (Lab Work)
Date 12 (Lab Work)
Test 12 (Lab Work)
Results 12 (Lab Work)
Comments 12 (Lab Work)
Date 13 (Lab Work)
Test 13 (Lab Work)
Results 13 (Lab Work)
Comments 13 (Lab Work)
Date 14 (Lab Work)
Test 14 (Lab Work)
Results 14 (Lab Work)
Comments 14 (Lab Work)
Date 15 (Lab Work)
Test 15 (Lab Work)
Results 15 (Lab Work)
Comments 15 (Lab Work)
Date 16 (Lab Work)
Test 16 (Lab Work)
Results 16 (Lab Work)
Comments 16 (Lab Work)
Date 17 (Lab Work)
Test 17 (Lab Work)
Results 17 (Lab Work)
Comments 17 (Lab Work)
Date 18 (Lab Work)
Test 18 (Lab Work)
Results 18 (Lab Work)
Comments 18 (Lab Work)
Date 19 (Lab Work)
Test 19 (Lab Work)
Results 19 (Lab Work)
Comments 19 (Lab Work)
Date 20 (Lab Work)
Test 20 (Lab Work)
Results 20 (Lab Work)
Comments 20 (Lab Work)
Date 21 (Lab Work)
Test 21 (Lab Work)
Results 21 (Lab Work)
Comments 21 (Lab Work)
Date 1 (Procedures)
Procedure 1 (Procedures)
Results 1 (Procedures)
Comments 1 (Procedures)
Date 2 (Procedures)
Procedure 2 (Procedures)
Results 2 (Procedures)
Comments 2 (Procedures)
Date 3 (Procedures)
Procedure 3 (Procedures)
Results 3 (Procedures)
Comments 3 (Procedures)
Date 4 (Procedures)
Procedure 4 (Procedures)
Results 4 (Procedures)
Comments 4 (Procedures)
Date 5 (Procedures)
Procedure 5 (Procedures)
Results 5 (Procedures)
Comments 5 (Procedures)
Date 6 (Procedures)
Procedure 6 (Procedures)
Results 6 (Procedures)
Comments 6 (Procedures)
Date 7 (Procedures)
Procedure 7 (Procedures)
Results 7 (Procedures)
Comments 7 (Procedures)
Date 8 (Procedures)
Procedure 8 (Procedures)
Results 8 (Procedures)
Comments 8 (Procedures)
Date 9 (Procedures)
Procedure 9 (Procedures)
Results 9 (Procedures)
Comments 9 (Procedures)
Date 10 (Procedures)
Procedure 10 (Procedures)
Results 10 (Procedures)
Comments 10 (Procedures)
Date 11 (Procedures)
Procedure 11 (Procedures)
Results 11 (Procedures)
Comments 11 (Procedures)
Date 12 (Procedures)
Procedure 12 (Procedures)
Results 12 (Procedures)
Comments 12 (Procedures)
Date 13 (Procedures)
Procedure 13 (Procedures)
Results 13 (Procedures)
Comments 13 (Procedures)
Date 14 (Procedures)
Procedure 14 (Procedures)
Results 14 (Procedures)
Comments 14 (Procedures)
Date 15 (Procedures)
Procedure 15 (Procedures)
Results 15 (Procedures)
Comments 15 (Procedures)
Date 16 (Procedures)
Procedure 16 (Procedures)
Results 16 (Procedures)
Comments 16 (Procedures)
Date 17 (Procedures)
Procedure 17 (Procedures)
Results 17 (Procedures)
Comments 17 (Procedures)
Date 18 (Procedures)
Procedure 18 (Procedures)
Results 18 (Procedures)
Comments 18 (Procedures)
Date 19 (Procedures)
Procedure 19 (Procedures)
Results 19 (Procedures)
Comments 19 (Procedures)
Date 20 (Procedures)
Procedure 20 (Procedures)
Results 20 (Procedures)
Comments 20 (Procedures)
Date 21 (Procedures)
Procedure 21 (Procedures)
Results 21 (Procedures)
Comments 21 (Procedures)
Month (Calendar)
Year (Calendar)
Date 1 (Calendar)
Date Text 1 (Calendar)
Date 2 (Calendar)
Date Text 2 (Calendar)
Date 3 (Calendar)
Date Text 3 (Calendar)
Date 4 (Calendar)
Date Text 4 (Calendar)
Date 5 (Calendar)
Date Text 5 (Calendar)
Date 6 (Calendar)
Date Text 6 (Calendar)
Date 7 (Calendar)
Date Text 7 (Calendar)
Date 8 (Calendar)
Date Text 8 (Calendar)
Date 9 (Calendar)
Date Text 9 (Calendar)
Date 10 (Calendar)
Date Text 10 (Calendar)
Date 11 (Calendar)
Date Text 11 (Calendar)
Date 12 (Calendar)
Date Text 12 (Calendar)
Date 13 (Calendar)
Date Text 13 (Calendar)
Date 14 (Calendar)
Date Text 14 (Calendar)
Date 15 (Calendar)
Date Text 15 (Calendar)
Date 16 (Calendar)
Date Text 16 (Calendar)
Date 17 (Calendar)
Date Text 17 (Calendar)
Date 18 (Calendar)
Date Text 18 (Calendar)
Date 19 (Calendar)
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Date 20 (Calendar)
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Date 21 (Calendar)
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Date 22 (Calendar)
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Date 23 (Calendar)
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Date 24 (Calendar)
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Date 25 (Calendar)
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Date 26 (Calendar)
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Date 27 (Calendar)
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Date 28 (Calendar)
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Text (Notes)
iTransition-Health Resources for Youth and Young Adults Websites and Online Resources
(Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration Office for Genetics and People with Special Health Care Needs For more information visit
httpphpadhmhmarylandgovgeneticsSitePageshomeaspx
bull ldquoMatrix for Including Health in the IEP and Transition IEPrdquo
(httpdeptswashingtoneduhealthtrdocumentsmatrix_ieppdf) - This resource is a chart which includes both the parts of the IEP and the Transition IEP
bull Parent Brief ldquoPromoting Effective Parent Involvement in Secondary Education and
Transitionrdquo (httpwwwncsetorgpublicationsviewdescaspid=2967) - This resource is from the National Center on Secondary Education and Transition which provides source of information for youth with disabilities and support person
Agencies to Support Health Care Transition
Maryland Department of Health and Mental Hygiene (DHMH) Office for Genetics and People with Special Health Care Needs (OGPSHCN) httpfhadhmhmarylandgovgenetics - This office provides services for children and youth with special health care needs
Maryland Center for Developmental Disabilities (MCDD) httpmcddkennedykriegerorg - This agency provides programs and resources to people with disabilities and their families
Maryland Developmental Disability Council (DD Council) httpwwwmd-councilorg - This agency provides leadership to ensure independence productivity integration and inclusion of individuals with disabilities in the community through promotion of systems change
Maryland Department of Disabilities (MDoD) and Governors Interagency Transition Council for Youth with Disabilities (IATC) httpwwwmdtransitionorg - This agency and council advances the rights and interests of people with disabilities so they may fully participate in their communities
Maryland Medical Care Programs httpmmcpdhmhmarylandgovSitePagesHomeaspx - This agency provides patient care coverage and services
Maryland State Department of Education (MSDE) httpwwwmarylandpublicschoolsorg ndash This agency prepares children with disabilities to move from school to the appropriate postsecondary outcomes
