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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.