Download Pediatric to Adult Care Transitions Tools Medical Summary

Pediatric to Adult Care
Transitions Tools
Medical Summary for Young Adults with
Physical Disabilities
This document should be shared with and carried by youth and families/caregivers.
Date Completed:
Date Revised:
Form completed by:
Contact Information
Name:
DOB:
Parent (Caregiver):
Address:
Cell #:
Home #:
E-Mail:
Nickname:
Preferred Language:
Relationship:
Best Time to Reach:
Best Way to Reach: Text
Phone
Email
Special information that the youth or family wants health care professionals to know (for example
information about youth’s goals, talents, communication preferences, access issues, decision-making, and
advance directives):
Provider’s rating of youth’s understanding of their diagnosis and the long term health implications.
___ very good
___ good
___fair
____ poor
o
Diagnoses and Current Problems
Problem
☐Primary Diagnosis
☐Secondary Diagnosis
☐Behavioral
☐Communication
☐Feed & Swallowing
☐Hearing/Vision
☐Learning
☐Orthopedic/Musculoskeletal
☐Physical Anomalies
☐Respiratory
☐Sensory
☐Stamina/Fatigue
☐Reproductive Health
☐Other
Health Insurance/Plan:
Details and Recommendations
Group and ID#:
Emergency Care Plan
Emergency Contact:
Preferred Emergency Care Location:
Relationship:
Phone:
Pediatric to Adult Care
Transitions Tools
Medical Summary for Young Adults with
Physical Disabilities
Common Emergent Presenting
Problems
Suggested Tests
Treatment Considerations
Special Concerns for Disaster:
Allergies and Procedures to be Avoided
Allergies
Reactions
To be avoided
☐ Medical Procedures:
☐ Medications:
Why?
Medications
Medications
Dose
Frequency
Medications
Dose
Frequency
Health Care Providers
Provider
Primary and Specialty
Clinic or Hospital
Phone
Fax
DME Provider
Agency
Contact Person
Phone
Fax
Contact Person
Phone
Fax
Community Provider
Agency
Prior Surgeries, Procedures, and Hospitalizations
Date
Date
Date
Baseline
Baseline Vital Signs: Ht
Baseline Neurological Status:
Most Recent Labs and Radiology
Test
EEG
EKG
X-Ray
C-Spine
MRI/CT
Wt
Date
RR
Result
HR
BP
Pediatric to Adult Care
Transitions Tools
Medical Summary for Young Adults with
Physical Disabilities
Other
Other
Other
Equipment, Appliances, and Assistive Technology (please include type, brand, size, and weight if
applicable):
☐Gastrostomy:
☐Adaptive Seating:
☐Wheelchair:
☐Tracheostomy:
☐Communication Device:
☐Orthotics:
☐Suctions:
Monitors:
☐Crutches:
☐Nebulizer:
☐Apnea:
☐O2:
☐Ventilator Support:
☐Cardiac:
☐Glucose:
☐Walker:
☐Other:
School and Work Information
School
Work
Contact Information
Contact Person:
Contact Information
Contact Person:
Phone:
Phone:
Youth signature
Print Name
Phone Number
Parent/Caregiver
Print Name
Phone Number
Primary Care Provider Signature
Care Coordinator Signature
Print Name
Print Name
Phone Number
Phone Number
Date
Date
Date
Pediatric to Adult Care
Transitions Tools
Medical Summary for Young Adults with
Physical Disabilities
Please attach the immunization record to this form.