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Mended Little HeartGuide

Introduction Contents About My Child’s Heart Please review this information with your child’s cardiologist. My child’s diagnosis: _____________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Date of diagnosis: _______________________________________________________________________________ In my own words, this means: ______________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Surgeries my child will need/has had, if any: __________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Procedures my child will need/has had, if any: _________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ In my own words, this is what will be/was done during my child’s surgeries and/or procedures: __________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ I can find more reliable medical information about my child’s heart condition here: ___________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Diagram of a Healthy Heart Here is a diagram of a heart without a congenital heart defect. About My Child’s Heart Medications (Use one copy of this form for each medication your child takes.) Medication Allergies: ________________________________________________ Pharmacy: ___________________________________________________ Phone: _________________________ Medication: Prescribed by: Date: What it is for: Possible side effects: Dosage: Time(s) to give it: Record of Giving Medication Date Time Time Time Time Comments Appointment Log Date Provider Reason Seen Next Appointment Diagram of My Child’s Heart Print this page and ask your child’s cardiologist to draw a picture of your child’s heart here. My Child’s Doctors Cardiologist Name: __________________________________________________________________________________________ Phone: ________________________ Email: ___________________________________________________________ Location: _______________________________________________________________________________________ Surgeon Name: __________________________________________________________________________________________ Phone: ________________________ Email: ___________________________________________________________ Location: _______________________________________________________________________________________ Pediatrician/ Family Doctor Name: __________________________________________________________________________________________ Phone: ________________________ Email: ___________________________________________________________ Location: _______________________________________________________________________________________ Specialist: (Type) ________________________________________________________________________________ Name: __________________________________________________________________________________________ Phone: ________________________ Email: ___________________________________________________________ Location: _______________________________________________________________________________________ Specialist: (Type) ________________________________________________________________________________ Name: __________________________________________________________________________________________ Phone: ________________________ Email: ___________________________________________________________ Location: _______________________________________________________________________________________ Other Specialists and Resources Social Worker Name: _________________________________________________________________________________________ Phone: ________________________ Email: __________________________________________________________ Location: ______________________________________________________________________________________ Physical Therapist Name: _________________________________________________________________________________________ Phone: ________________________ Email: __________________________________________________________ Location: ______________________________________________________________________________________ Occupational Therapist Name: _________________________________________________________________________________________ Phone: ________________________ Email: __________________________________________________________ Location: ______________________________________________________________________________________ Nutritionist Name: _________________________________________________________________________________________ Phone: ________________________ Email: __________________________________________________________ Location: ______________________________________________________________________________________ Early Intervention Services Name: _________________________________________________________________________________________ Phone: ________________________ Email: __________________________________________________________ Location: ______________________________________________________________________________________ 1 Growth Tracking Keep track of your child’s growth here. Bear in mind that children with CHD are sometimes smaller than their peers. The important thing is that they are growing steadily. Also, understand that surgeries and illnesses may cause temporary delays in growth. When your child is a baby, you may want to track growth more frequently. Date Height Weight Head Circumference Checked By Table of Go To SECTION About My Child’s Heart Medications Diagram of My Child’s Heart Other Specialists and Resources Diagram of a Healthy Heart Appointment Log My Child’s Doctors Growth Tracking 86


Mended Little HeartGuide
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