CROWSTONE PREPARATORY SCHOOL
         
Individual Healthcare Plan (IHP)
         
         
Child Details        
Last Name:    
First Name:    
Class:    
Date of Birth:   DD MM YY
Medical diagnosis or condition:    
CPS IHP Inception Date:   DD MM YY
Review date:   DD MM YY
         
Family Details   Parent/Guardian/Carer 1 Parent/Guardian/Carer 2 Parent/Guardian/Carer 3
Last Name:        
First Name:        
Phone no. (work):        
(home):        
(mobile):        
Relationship to child:        
Phone no. (work):        
(home):        
(mobile):        
Address:        
         
Town/City:        
County:        
Post Code:        
Mark Child's Main Residence (x):        
         
Clinic/Hospital Contact        
Name:    
Phone no.:    
         
General Practitioner        
Name:    
Phone no.:    
         
Plan Specifics        
Who is responsible for providing support in school
     
         
Describe medical needs and give details of child’s symptoms, triggers, signs, treatments, facilities, equipment or devices, environmental issues etc.
Medical Needs:    
Symptoms:    
Triggers:    
Signs:    
Treatments:    
Facilities:    
Equipment or Devices:    
Environmental Issues:    
Additional Information:    
         
Name of medication, dose, method of administration, when to be taken, side effects, contra-indications, administered by/self-administered with/without supervision
Medication (name incl. brand):    
Dose:    
Method:    
To Be Taken:    
Side Effects:    
Contra-Indications:    
To be administered by (can be “self”):    
     
Daily care requirements    
 
         
Specific support for the pupil’s educational, social and emotional needs
 
         
Arrangements for school visits/trips etc
 
         
Other information        
 
         
Describe what constitutes an emergency, and the action to take if this occurs
Emergency Situation:    
Action:    
         
Who is responsible in an emergency (state if different for off-site activities)
 
         
Plan developed with:    
         
Staff training needed/undertaken – who, what, when
Who What Training When Date Completed
       
       
       
       
         
Additional Notes:        
 

This form is based on the DfE document “Supporting Pupils With Medical Conditions (Templates) (May 2014).