Jan2020-KidsHealthPlanner

Children’s Health Journal

Copyright Information

General Information

Parent Details Mother Maiden Name Blood Group Full Name Date of birth Place of birth Birth weight Birth length Eye Color Email Address: Contact Information NOTES Mobile Number: Father Full Name Date of birth Place of birth Birth weight Birth length Eye Color Blood Group Email Address: Contact Information NOTES Mobile Number:

Emergency Contacts Name Mobile Number: Email Address: Relationship: Address: Notes: Name Mobile Number: Email Address: Relationship: Address: Notes: Name Mobile Number: Email Address: Relationship: Address: Notes:

Medical Contacts Hospital Name Telephone Number: Email Address: Contact Person: Address: Notes Family GP Name Telephone Number: Email Address: Emergency Number: Address: Notes: Dentist Name Telephone Number: Email Address: Emergency Number: Address: Notes:

Medical Contacts FaPmeidlyiaGtrPiciaNnameName Telephone Number: Email Address: Emergency Number: Address: Notes: Specialist Name Specialty: Telephone Number: Email Address: Emergency Number: Address: Notes: Specialist Name Specialty: Telephone Number: Email Address: Emergency Number: Address: Notes:

Medical Contacts FamSiplyecGiaPlistNameName Specialty: Telephone Number: Email Address: Emergency Number: Address: Notes: Specialist Name Specialty: Telephone Number: Email Address: Emergency Number: Address: Notes: Specialist Name Specialty: Telephone Number: Email Address: Emergency Number: Address: Notes:

Medical Insurance FCaommiplyaGnyP Name Telephone Number: Email Addddrreessss:: ECmonetragcetnPceyrNsounm: ber: Address: NPooltiecys:Number Policy Type Notes Date Doctor Claims Visit for Claim Amt Settled Patient

Medical Insurance Family GP Name Claims Claim Amt Settled EmDaailteAddress: Doctor Patient TelephonVeisNitufmobr er: Emergency Number: Address: Notes:

Medical Insurance Family GP Name Claims Claim Amt Settled EmDaailteAddress: Doctor Patient TelephonVeisNitufmobr er: Emergency Number: Address: Notes:

Medical Insurance Family GP Name Claims Claim Amt Settled EmDaailteAddress: Doctor Patient TelephonVeisNitufmobr er: Emergency Number: Address: Notes:

Family Medical History Family GP Name Maternal Paternal Email ACdodnrdeistsio: n Mother Father TeGlerapnhdo-ne NumGbraenr:d- Grand- Grand- mother father mother father Emergency Number: High Blood Pressure Address: Low Blood Pressure Stroke Notes: Heart Attack Glaucoma Asthma Epilepsy Diabetes Cancer: Type Obesity Substance Addiction - Specify Eating Disorder Allergies - Specify Mental Disorders - Specify

Family Medical History Family GP Name Family Medical History Notes Telephone Number: Email Address: Emergency Number: Address: Notes:

Family Medical History Family GP Name Family Medical History Notes Telephone Number: Email Address: Emergency Number: Address: Notes:

Children’s Health Trackers

Child’s Name

Child Information Full Name Date of birth Place of birth BLOOD GROUP Birth weight Birth length Skin color Agpar score Eye color Complications Type of Birth NOTES Medical Conditions Condition Date Diagnosed Doctor Notes Allergies Allergy Date Diagnosed Symptoms Treatment

Immunization Record Name Age Immunization Date Received Medical Practitioner Reactions / Notes Birth HepB 1 – 2 months HepB 2 months DTaP 2 months Hib 2 months IPV 2 months PCV 2 months 4 months RV 4 months DTaP 4 months Hib 4 months IPV 4 months PCV 6 months RV 6 months DTaP 6 months Hib 6 months PCV 6 – 18 months RV 6 – 18 months HepB 12 – 15 months IPV 12 – 15 months Hib 12 – 15 months MMR PCV 12 – 15 months Chickenpox (Varicella) 12 – 23 months HepA 15 – 18 months DTaP 4 – 6 years DTaP 4 – 6 years MMR 4 – 6 years IPV 4 – 6 years Varicella 11 – 12 years HPV (first) 11 – 12 years Tdap 11 – 12 years HPV (second) Meningococcal 11 – 12 years conjugate Meningococcal 16 – 18 years conjugate (booster) MenB 16 – 18 years

Immunization Notes Name

Growth Chart Name Age Weight Length / Height Head Circumference BMI 21 years 20 years 19 years 18 years 17 years 16 years 15 years 14 years 13 years 12 years 11 years 10 years 9 years 8 years 7 years 6 years 5 years 4 years 3 years 30 months 24 months 18 months 15 months 12 months 9 months 6 months 4 months 2 months 1 month 3 – 5 days Birth

Tooth Chart Name 1 2 3 UPPER 4 5 5 LOWER 4 3 2 1 Tooth Approx. Erupt By Approx. Lose By ERUPTED LOST 1. Central Incisor LEFT RIGHT LEFT RIGHT 2. Lateral Incisor 3. Canine 8 – 10 months UPPER 4. First Molar 8 – 10 months 6 – 7 years 5. Second Molar 16 – 20 months 7 – 8 years 15 – 21 months 10 – 12 years 1. Central Incisor 20 – 24 months 9 - 11 years 2. Lateral Incisor 10 – 12 years 3. Canine 6 – 9 months 4. First Molar 5 – 21 months LOWER 5. Second Molar 15 – 21 months 6 – 7 years 15 – 21 months 7 – 8 years 20 – 24 months 9 – 12 years 9 – 11 years 10 – 12 years

Wellness Checkups Name Age Date Time Practitioner Check For BIRTH weight, length, and head circumference, feeding, bladder and bowel, sleep Concerns: Notes: Age Date Time Practitioner Check For 3 – 5 DAYS weight, length, and head circumference, feeding, bladder and bowel, sleep Concerns: Notes: Age Date Time Practitioner Check For 1 MONTH weight, length, and head circumference, feeding, bladder and bowel, sleep, development Concerns: Notes: Age Date Time Practitioner Check For 2 MONTHS weight, length, and head circumference, feeding, bladder and bowel, sleep, development Concerns: Notes: Age Date Time Practitioner Check For 4 MONTHS weight, length, and head circumference, feeding, bladder and bowel, sleep, development Concerns: Notes:

Wellness Checkups Name Age Date Time Practitioner Check For 6 MONTHS weight, length, and head circumference, feeding, bladder and bowel, sleep, development Concerns: Notes: Age Date Time Practitioner Check For 9 MONTHS weight, length, and head circumference, feeding, bladder and bowel, sleep, development screening Concerns: test Notes: Age Date Time Practitioner Check For 12 weight, length, and head circumference, eating, MONTHS bowel, sleep, development Concerns: Notes: Age Date Time Practitioner Check For 15 weight, length, and head circumference, eating, MONTHS bowel, sleep, development Concerns: Notes: Age Date Time Practitioner Check For 18 weight, length, and head circumference, eating, MONTHS bowel, sleep, development and autism screening tests Concerns: Notes:

Wellness Checkups Name Age Date Time Practitioner Check For 2 YEARS weight, height, head circumference, BMI, eating, bladder and bowel, sleep, development, autism Concerns: screening test Notes: Age Date Time Practitioner Check For 2.5 YEARS weight, height, BMI, eating, bladder and bowel, sleep, development screening test Concerns: Notes: Age Date Time Practitioner Check For 3 YEARS weight, height, BMI, eating, bladder and bowel, sleep, development, BP, vision test Concerns: Notes: Age Date Time Practitioner Check For 4 YEARS weight, height, BMI, eating, bladder and bowel, sleep, development, BP, vision & hearing tests Concerns: Notes: Age Date Time Practitioner Check For 5 YEARS weight, height, BMI, eating, bladder and bowel, sleep, development, BP, vision & hearing tests Concerns: Notes:

Wellness Checkups Name Age Date Time Practitioner Check For 6 YEARS weight, height, BMI, eating, bathroom habits, sleep, physical activity, development, BP, vision & Concerns: hearing tests Notes: Age Date Time Practitioner Check For 7 YEARS weight, height, BMI, eating, bathroom habits, sleep, physical activity, development, BP Concerns: Notes: Age Date Time Practitioner Check For 8 YEARS weight, height, BMI, eating, bathroom habits, sleep, physical activity, development, BP Concerns: Notes: Age Date Time Practitioner Check For 9 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP Concerns: Notes: Age Date Time Practitioner Check For 10 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, vision & hearing tests Concerns: Notes:

Wellness Checkups Name Age Date Time Practitioner Check For 11 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, hearing test Concerns: Notes: Age Date Time Practitioner Check For 12 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, vision & hearing tests, Concerns: screening for depression Notes: Age Date Time Practitioner Check For 13 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, hearing test, screening Concerns: for depression Notes: Age Date Time Practitioner Check For 14 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, hearing test, screening Concerns: for depression Notes: Age Date Time Practitioner Check For 15 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, vision & hearing tests Concerns: Notes:

Wellness Checkups Name Age Date Time Practitioner Check For 16 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, vision & hearing tests Concerns: Notes: Age Date Time Practitioner Check For 17 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, vision & hearing tests Concerns: Notes: Age Date Time Practitioner Check For 18 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, hearing test, screening Concerns: for depression Notes: Age Date Time Practitioner Check For 19 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, vision & hearing tests, Concerns: screening for depression Notes: Age Date Time Practitioner Check For 20 YEARS weight, height, BMI, eating, sleep, physical activity, growth & development, BP, vision & hearing tests, Concerns: screening for depression Notes:

Wellness Checkups Name Age Date Time Practitioner Check For 21 YEARS growth & development, BP, vision & hearing tests, screening for depression Concerns: Notes: Notes

Wellness Checkups Name Notes

Dental Checkups Name Date Time Practitioner Notes

Dental Checkups Name Date Time Practitioner Notes

Medical Appointments Name Date Time Practitioner Reason for visit Notes

Medical Appointments Name Date Time Practitioner Reason for visit Notes

Medical Appointments Name Date Time Practitioner Reason for visit Notes

Symptoms Tracker Name Date Symptom Mild Severe Medication Notes -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|-

Symptoms Tracker Name Date Symptom Mild Severe Medication Notes -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|-

Symptoms Tracker Name Date Symptom Mild Severe Medication Notes -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|-

Symptoms Tracker Name Date Symptom Mild Severe Medication Notes -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|- -|-|-|-|-|-|-|-|-|-|-

Medication Tracker Name Start End Medication Dosage Breakfast Notes Date Date Lunch Dinner Other Times

Medication Tracker Name Start End Medication Dosage Breakfast Notes Date Date Lunch Dinner Other Times

Medication Tracker Name Start End Medication Dosage Breakfast Notes Date Date Lunch Dinner Other Times

Medication Tracker Name Start End Medication Dosage Breakfast Notes Date Date Lunch Dinner Other Times

Notes

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Child’s Name

Child Information Full Name Date of birth Place of birth BLOOD GROUP Birth weight Birth length Skin color Agpar score Eye color Complications Type of Birth NOTES Medical Conditions Condition Date Diagnosed Doctor Notes Allergies Allergy Date Diagnosed Symptoms Treatment