Care Notebook Sample

Provided by Childhood Health Associates of Salem

The following Care Notebook is designed to help you organize and keep track of your child's care. Please take it with you to all appointments for maximum results.


Table of Contents


1. All About Me: A description of your child's special needs to be presented to providers.

2. To Do List: A way to keep track of upcoming appointments, phone calls to make, equipment servicing etc.

3. Calendar: To help keep track of appointments.

4. Medical Visit Check Sheet: A tool to help Doctors visits be as productive as possible and reduce questions about follow-up.

5. Tips For A Good Visit: A tool to help providers learn more about your child's individual needs.

6. Important Phone Numbers: A form to keep track of providers phone numbers.

7. Medication Log: A form to keep track of current medications and their dosage as well as dates of discontinued medications.

8. Daily Medication Schedule: A form to keep track of all administered medication by day, time and dosage.

9. Height and Weight: A form to keep track of your child's growth.

10. Laboratory Flow Sheet: For children who have frequent labs, this will help keep track of past and current lab results.

11. Medical History  and  Developmental History: This will enable you, if fIlled out, to answer any question a provider may ask about cause for condition, past surgeries, etc.

12. Equipment Log: Designed to keep track of vendors for equipment, last dates of service and product information.

13. People Who Can Consent To Care For My Child: Contact information concerning others who are capable of caring for your child in an emergency.