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Individual Healthcare Plan

The Stoke Poges School

Child's name:


Date of birth:

Child's address:

Medical diagnosis or condition:

Today's date:

Review date of condition:

Family Contact Information

Parent/Carer name:

Relationship to child:

Phone number:

Alternative phone number:

Clinic/Hospital Contact


Phone number:



Phone number:

Who is responsible for providing your child with support in school?

Medical Needs

Describe medical needs and give details of child's symptoms, triggers, signs, treatments, facilities, equipment or devices environmental issues etc.

Name of medication, dose, method of administration, when to be taken, side effects, contra-indications, administered by/self-administered with/without supervision.

How can we support your child's needs in school?

Does your child have any specific educational, social and emotional needs which they may require support with?

Please describe any specific requirements for school visits/trips etc.

Describe what constitutes an emergency and the action to take if this occurs.

Who is responsible in an emergency (state if different for off-site activities).

Any other information:

For office use only

Plan developed with:

Staff traning needed/undertaken - who, what, when?

Form copied to: