Handouts and Forms 
supporting those with heart defects

Copyright 2002-2019 California Heart Connection. All rights reserved.
Please let us know if you find these handouts and forms helpful.  If you have any feedback on these forms, or suggestions for additional handouts or forms, please contact us at:  1-877-824-3463 or email Debbie Hilton Kamm at info@caheartconnection.org.  We are always looking for additional information that can help those with heart defects.

Handouts and Forms
Find forms for each of the following topics below:

Help when receiving a diagnosis:

Resource Guide (updated Feb. 2019)
(5-page handout)
Compiled list of information critical to those with children with CHD.  Includes information on medical issues to clarify with the physician, helpful products, Early Intervention services, insurance/financial information, and much more.  This Guide is an invaluable tool for physicians, case managers and parents of children with CHD.   

What to Ask the Surgeon and Hospital
(2-page handout) 
A list of questions to help compare hospitals to aid in the patient's decision-making regarding treatment options

What to Ask the Insurance Company and Common Insurance Terms
(4-page handout)
Important terms to better understand coverage and costs with a list of questions to ask about specific benefits, restrictions, out-of-pocket costs, etc.

Internet Resources
(1-page handout) 
Selected online resources for heart diagrams and information on specific diagnoses

Emergency and Follow-Up Forms:

Emergency Information Sheet - (1-page form)
Information every parent should have available in case of emergency with space to fill in important information.  Copies can be distributed to caregivers, school administrators, and kept in the car or other areas in case of emergency.

When to Call the Doctor or 911 - (1-page form)
Form to be filled out by physician which delineates which symptoms warrant a call to the doctor, or a trip to the ER.  Helps to decrease parent's anxiety trying to determine the severity of a medical issue and gives them clear instructions for specific symptoms.

Follow-up Care - (2-page form)
Overwhelmed parents may be confused as to the many different follow-up and other appointments that are necessary.  This form allows physicians to fill in approximate timelines for future appointments, vaccinations, therapies, etc. which helps parents keep current with important medical appointments.

Medication Tips - (2-page form)
Useful tips on administering medications properly and more easily to children and infants which is often a source of significant stress for families.

Medication Summaries
(2 pages each, 8 common medications)
Benefits and possible side effects of many common pediatric heart medications, with fill-in area for physicians to indicate dosage information and special instructions such as what to do if a dose is missed, storage information and more.  Medication summaries courtesy of PedHeart Prints Patient Education Software, developed by Scientific Software Solutions.

Hospital Stays:

Preparing For Your Child's Hospital Stay
(3-page handout)
Tips and suggestions for preparing for surgery help parents understand what to expect, what to bring, and questions to ask prior to a procedure or hospital stay.

Medical Specialists
(6-page handout and form)
Families are often confused about the function of each of the different medical specialists they come in contact with.  This form includes a description of different medical specialties and appropriate questions to ask each specialist.  Space is provided to include contact information for each for referrals.

School Forms:

Overview of Services
Information on Early Intervention, 504 plans, IEPs, Health Plans, and receiving accommodations in college.

Development Issues and CHD (new 2017)
Information on common developmental delays, learning issues and behavioral problems that may affect some children with CHD.

Health Summary Form for School
A simple form for teachers, substitutes, and others to know the major issues your child has, and what actions should be taken.  Includes a confidentiality waiver so the information can be distributed to other parents or aides as needed.

Sample 504 Plan - A sample 504 plan that can be used as a guideline to bring up issues with school administrators to create appropriate accommodations for your child.  

Physical Activity - (1-page form)
Form to clarify appropriate activities for the child with CHD.  Excellent tool for clarification for parents, care-givers and schools so that the patient's health is not compromised, and the child is not excluded from activities that are not dangerous. 
Below you will find a description of each of the forms available.  All forms are downloadable for free.   

Physician Instructions: