American College of Physicians
This document should be completed by medical providers, in collaboration with youth and their caregivers. A copy of this completed document should be shared with and carried by youth and caregivers to facilitate comprehensive information transfer and chart review when establishing care with new medical providers.Date Completed:Date Revised:Form completed by:Contact InformationName:Nickname:DOB:Preferred Language:Address:Cell #:Home #:Best Time to Reach:E-Mail:Best Way to Reach:TextPhoneEmailParent (Caregiver):Relationship:Address:Cell #:Home #:Best Time to Reach:E-Mail:Best Way to Reach:TextPhoneEmailHealth Insurance/Plan:Group and ID #:Please add special information about strengths that the youth/caregiver wants their new health care team to know:Developmental DisabilityVerbalNon-VerbalNervous System: Sensory System: Other:Autism spectrum disorderCerebral palsyDown syndromeFetal Alcohol SyndromeFragile XIntellectual disabilityRett syndromeSpina bifidaTourette syndromeOther (Specify):AvoidantSeekingImpairedVisualAuditoryGustatoryOlfactoryTactileProprioceptiveVestibularOther (Specify):ADHDHearing impairmentVisual impairmentSeizuresCardiac ConditionObesityOSAOther (Specify): Degenerative: Co-occurring Psychological Issues:Metabolism:Muscular dystrophyOther (Specify):DepressionAggressionAnxietyRelationalSelf-injurious BeahviorOther (Specify):Congenital hypothyroidism PhenylketonuriaOther (Specify):Etiology Genetic/Chromosomal Prenatal Substance Exposure Prenatal Viral Exposure Preterm Birth Birth Complication Acquired or Traumatic Brain Injury OtherAdaptive Functioning Domains Communication: Social: Self Direction: Community Activities: Work: Functional Academics: Functional Grade Level: Date Tested: FSIQ: Date Tested: Home Living: Leisure: Sleep Issues: Nutritional Issues: Quality of Life Issues: Safety Issues:Emergency Care Plan Emergency Contact:Relationship:Phone: Preferred Emergency Care Location:Common Emergent Presenting ProblemsSuggested TestsTreatment Considerations Special Concerns for Disaster:Allergies and Procedures to be Avoided Allergies ReactionsTo be avoidedWhy? Medical Procedures: Medications:Diagnoses and Current ProblemsProblemDetails and Recommendations Primary Diagnosis Secondary Diagnosis Behavioral Communication Feed & Swallowing Hearing/Vision Learning Orthopedic/Musculoskeletal Physical Anomalies Respiratory Sensory Stamina/Fatigue OtherMedicationsMedicationsDoseFrequencyMedicationsDoseFrequencyHealth Care ProvidersNamePhoneFaxPrimary Care ProviderSpecialty Provider (if applicable)Specialty Provider (if applicable)Specialty Provider (if applicable)Clinic or Hospital Provider(s)Speech Therapist Physical Therapist Occupational TherapistMental Health/Psychiatry OtherPrior Surgeries, Procedures, and HospitalizationsDateDateDateDateDateBaselineBaseline Vital Signs:Ht.Wt.RRHRBP Baseline Neurological Status:Most Recent Labs and RadiologyTestDateResultEEGEKGX-RayC-SpineMRI/CTOther (Specify):Equipment, Appliances, and Assistive Technology Gastrostomy Adaptive Seating Wheelchair Tracheostomy Communication Device Orthotics Suctions Monitors: Crutches NebulizerApneaO2 WalkerCardiacGlucose Other (Specify):School and Community InformationAgency/SchoolContact InformationContact Person: Phone:Contact Person: Phone:Contact Person: Phone:________________________________________________________________________________Patient/Guardian Signature Print Name Phone Number Date________________________________________________________________________________Primary Care Provider Signature Print Name Phone Number Date________________________________________________________________________________Care Coordinator Signature Print Name Phone Number Date ................
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