Handouts and Forms
Find forms for each of the following topics below:
Help when receiving a diagnosis:
(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.
(2-page handout)
A list of questions to help compare hospitals to aid in the patient's decision-making regarding treatment options
(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.
(1-page handout)
Selected online resources for heart diagrams and information on specific diagnoses
Emergency and Follow-Up Forms:
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.
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.
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.
Useful tips on administering medications properly and more easily to children and infants which is often a source of significant stress for families.
(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:
(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.
(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:
Information on Early Intervention, 504 plans, IEPs, Health Plans, and receiving accommodations in college.
Information on common developmental delays, learning issues and behavioral problems that may affect some children with CHD.
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.
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.
