Care Notebook

In caring for a child with special health care needs, families get information and paperwork from many sources. The care notebook is designed to help organize the information in a central place to assist both families and providers. You may download the complete notebook and compile in your own binder or download separate forms by clicking on the Sections list below.

• Collaborative Care Notebook ( 467 KB)
  From Utah Family Voices, this care notebook in PDF format incorporates forms from many other states. Use selected pages or the entire notebook.

Tips on setting up your care notebook ( 191 KB)
One-page.

Al cuidar la salud de su niño con necesidades especiales, usted puede recibir copias e información de muchas fuentes. Un Cuaderno de registro le facilitara a organizarse mejor con la información más importante. Con un cuaderno de registros le será mucho más fácil para usted encontrar y compartir una porción de información con otros quienes son parte del equipo del cuidado de su niño.

Siga estos pasos para preparar el notebook (cuaderno deregistro) de su Niño ( 149 KB)

Completo Care Notebook ( 1.3 MB)

Pages to keep track of Appointments & Care / Paginas para Mantener las Citas y el Cuidado

• Appointment Log ( 43 KB) / Registro de las Citas ( 139 KB)
• Diet Tracking ( 26 KB) / Formulario de Dieta ( 70 KB)
• Equipment ( 95 KB) / Equipos o Articulos ( 72 KB)
• Growth Tracking Form ( 36 KB) / Formulario para Mantener Su Crecimiento ( 153 KB)
• Hospital Stay Tracking Form ( 29 KB) / Formulario de Estadia en el Hospital ( 70 KB)
• Lab Work and Tests ( 35 KB) / El Laboratorio Trabajo Pruebas Procedimientos ( 135 KB)
• Medical Bill Communication Log ( 42 KB) / Libro de Comunicacion de Fracturas Medicas ( 114 KB)
• Medical Surgical Highlights ( 35 KB) / Los Momentos Culminantes Quirurgicos Medicos ( 117 KB)
• Medications ( 32 KB) / Medicaciones ( 103 KB)
• Notes ( 19 KB) / Notas ( 30 KB)
• Supplies ( 53 KB) / Provisiones ( 104 KB)

Pages to create a care summary: Abilities & Special Care Needs / Las páginas para crear un resumen del cuidado: Las Habilidades y las Necesidades del Cuidado Especial

• Activities of Daily Living ( 23 KB) / Las Actividades Diarias ( 91 KB)
• Care Schedule ( 46 KB) / Horario del Cuidado ( 127 KB)
• Communication ( 20 KB) / Comunicacion ( 90 KB)
• Coping/Stress Tolerance ( 23 KB) / Sobrellevar Tolerar el Estres ( 91 KB)
• Mobility ( 18 KB) / Mobilidad ( 89 KB)
• Nutrition ( 18 KB) / Nutricion ( 89 KB)
• Respiratory ( 20 KB) / Respiratorio ( 87 KB)
• Rest/Sleep ( 23 KB) / Dormir Reposar ( 87 KB)
• Social/Play ( 31 KB) / Social Juego ( 92 KB)
• Transitions ( 35 KB) / Transiciones ( 94 KB)

Pages to create a Care Team & Resource List / Paginas para crear un Equipo Y Lista De Recursos

• Child Care ( 51 KB) / Cuidado De Ninos ( 96 KB)
• Early Intervention ( 94 KB)
• School Contacts Sample, Care Notebook (Utah) ( 75 KB)
• Family Information ( 114 KB) / Informacion Familiar ( 88 KB)
• Family Support Resources ( 72 KB) / Recursos de Apoyo Familiar ( 91 KB)
• Home Care Providers ( 47 KB) / Cuidado en la Casa ( 63 KB)
• Insurance ( 48 KB) / Fuentes de Ayuda Economica S ( 61 KB)
• Medical Dental Providers ( 99 KB) / Medico Dental ( 120 KB)
• Pharmacy ( 60 KB) / Farmacia ( 96 KB)
• Recreation ( 348 KB) / Oportunidades de Recreacion ( 101 KB)
• Respite Care ( 56 KB) / Cuidado De Descanso Respite ( 56 KB)
• Association for Utah Community Health (AUCH) / Contactos de la Escuela ( 109 KB)
• Special Transportation ( 55 KB) / Transportacion Especial ( 63 KB)
• Therapists ( 45 KB) / Terapistas ( 63 KB)

• Building Your Care Notebook (AAP)
  The American Academy of Pediatrics provides a central place with links to several forms from many states. For families that are new to making care notebooks, we suggest you pick one form and try filling it out before downloading other forms.

• Tracking Medical Bills ( 125 KB)
  This form, developed for Tennessee's Family Information Notebook, provides a way to track bills including dates, insurance company, who paid, and more. For a PDF version and other forms, see the Care Notebook page.
• Weekly Medication Diary ( 99 KB)
• Portable Medical Summary ( 70 KB)
  A 2-page form to keep track of medical information including diagnoses, medications, equipment, hospitalizations, and insurance.
• Focus Sheet ( 27 KB)
  This form helps parents decide what they want to focus on during the appointment with the doctor and includes places for questions (behavior problems, family needs, etc.); places for things to bring (lab results, reason for visit, etc.); and places to write thing to remember after the appointment (next visit, treatment plan, etc.).
• My Health Passport (FCIC) ( 539 KB)
  This passport can be filled in with important information to help health professionals better support children with special needs during hospital or clinic visits; Florida Center for Inclusive Communities.

• Rhode Island Asthma Action Plan (RI DOH) ( 625 KB)
  Asthma Action Plan for children with sections to be completed by physician/health care provider and parent, including information about symptoms and medication; Rhode Island Department of Health Asthma Control Program.
• Rhode Island Asthma Action Plan - Spanish (RI DOH) ( 606 KB)
  En español. Asthma Action Plan for children with sections to be completed by physician/health care provider and parent, including information about symptoms and medication; Rhode Island Department of Health Asthma Control Program.

For more forms, see the Forms for Education and Planning for Emergencies pages.