Prosocial Applications, Inc. - Caregiver Alliance Web Services™

I. BACKGROUND INFORMATION
John Anastasio
Address Line 1	220 Green Duck Drive	Birth Date	02/11/1989
Address Line 2		Gender	Male
City	Boulder	State	CO
County		Zip Code	80302
Emergency Plan		Health Transition Plan
Primary Language		Needs an interpreter?
JOHN ANASTASIO'S PRIMARY CAREGIVER
First Name		Last Name
Address Line 1
Address Line 2
City		State
County		Zip Code
Primary language		Needs an interpreter?
Relationship to Youth

Company	Event Date	Policy No.
II. JOHN ANASTASIO'S HEALTH INSURANCE
Academy Life Insurance Company	08/29/2006	123
Medicaid	11/10/2006	9327

Provider	Event Date	Specialty	Diagnostic Code	Diagnosis	Entry
III. JOHN ANASTASIO'S MEDICAL HISTORY
DonaldJones	07/19/2006	General Practice	314.00	ADD CHLD WITHOUT MENTION HYPERACTV	John takes Ritalin for attention at school.
DrPageFishman	11/21/2006	General Practice	493.9	UNSPECIFIED ASTHMA

Immunization	Event Date	Entry
IV. JOHN ANASTASIO'S IMMUNIZATIONS
Measles-Mumps-Rubella (MMR)	11/21/1989
Polio	02/11/1990
Chickenpox (Varicella)	02/11/1990
Tetanus-Diphtheria	10/09/1995

Event	Event Date	Entry
V. JOHN ANASTASIO'S ALLERGIES
COMPAZINE-severe lockjaw reaction	05/16/2005	Compazine prescribed yesterday by Dr. Imagio to John to treat nausea and other stomach flu symptoms. After John took the first dose, his jaw was locked together. I didn't know what was happening, but drove him to the ER at Brown Hospital where lockjaw was diagnosed and an anti-histamine was administered by injection.
Penicillin	11/21/2006

Prescribing Physician	Event Date	Medication	Dosage	Prescription #	Entry
VI. JOHN ANASTASIO'S MEDICATION & SUPPLEMENTS
DrPageFishman	04/21/2001	Ritalin	10 mg 3x per day	8812334	Prescribed by Dr. Fishman 4/21/01 to improve concentration in school.
DrPageFishman	11/21/2006	Albuterol Aerosol	2 puffs as needed	1345-09	For asthma

Height in Inches

Weight in Pounds

Body Mass Index

Is a growth assessment linked to care plan notes?

Difficult feeding issues?

Is a feeding evaluation linked to care plan notes?

Is a swallow study linked to care plan notes?

Is a nutrition assessment linked to care plan notes?

Age appropriate textures and feeding?

Special caloric, nutrient, or fluid intake needs?

Internal Feeding?

Formula?

Rx?

Nutrition supplement products?

Are nutrition issues identified on IFSP or IEP linked to care plan notes?

Dietitian services?

Other diet or nutrition concerns?

JOHN ANASTASIO'S DIETITIANS/NUTRITIONISTS
No dietitians or nutritionists have been entered,

VIII. JOHN ANASTASIO'S COMMUNITY RESOURCES
Is an Individualized Family Service Plan (IFSP) linked to care plan notes?
Is an Individualized Education Plan (IEP) linked to care plan notes?
Is a foster care plan linked to care plan notes?
Is a court order linked to care plan notes?
Is a Health Care Action Plan linked to care plan notes?
Is a Health Transition Plan linked to care plan notes?
Is an Emergency Plan linked to care plan notes?

Specialty	Provider	Event Date
IX. JOHN ANASTASIO'S HEALTH & HUMAN SERVICE PROVIDERS
General Practice	DonaldJones	07/19/2006
General Practice	DrPageFishman	11/21/2006

Does family need help with resources?
Does family need respite care?
Does family need transportation?

X. JOHN ANASTASIO'S COORDINATED CARE PLAN For each member of this care plan team, identify an action item, related to youth needs, and a due date.
Who, as the client account administrator, is coordinating the design or revision of this care plan?
What youth needs (in plain language) are the focus of this care plan?
What youth problem (in diagnostic terms) is the focus of this care plan?
What action will be taken to address this problem?
Who (team member) will be responsible for completion of this action item?
On what date is the completed action item due?
Who (Supervisor) will confirm completion of the action item?

Coordinator	Action Item	Need	Problem	Due Date	Responsible	Contact
Marjorie Anastasio	Tutoring before school	Finishing school year	ADD OF CHILDHOOD WITH HYPERACTIVITY	5/21/2007	DonaldJones	MarjorieAnastasio