Student Individual Healthcare Plan Wilmslow High School Student Individual Healthcare Plan Student’s name……………………..………………………………………………………………….… Date of Birth…………………………… Tutor Group……….…….….. Student’s address………………..…………………………………………..………..……..……….…. ………………………………………………………………………….Postcode…………….…………. Date plan created………………………. Review date…..................................................... Medical diagnosis/condition……………………………………..……………………..……..….. Please note there are separate healthcare plans for management of Asthma, Diabetes, Epilepsy and Anaphylaxis Specialist Healthcare professionals involved Name and role Contact telephone number 1. Describe signs, symptoms and any triggers of the medical condition: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… 2. Will your child require any support (including educational, social, emotional) to manage their medical condition during the school day? YES/NO If YES, please give details; ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………….…………………..

Name…………………………………………..Tutor group………... Student Individual Healthcare Plan cont… Name…………………………………………..Tutor group………... 3.a Will your child require any medication or treatment within the school day? YES/NO If YES, please give details (dose, method of administration, when to be taken, side effects, contra indications and storage information for any medication); …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… A separate Administration of Medicines form will require completion for each prescribed medication listed above if staff are required to administer any medication (see back sheet) 3.b May your child self manage their own medication? YES/NO If YES, please complete a request form for each medication (see back sheet) 4. Are there any particular instructions in the event of an emergency? YES/NO If YES, please give details ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… Signed (parent/carer)…………………..…………..........Date……………... Office Use: Date Details Signature Staff training identified Information shared with all teachers Information on SIMS Information in Medical Needs Booklet