MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION HEALTH CARE INFORMATION SUMMARY
Name	DOB	DCN	Resource Home
Current health care / behavioral health providers:
Type	Name	Clinic/address
If Other or Specialist, explain here:
Current illnesses/health conditions for which child/youth is presently being treated - include any follow-up instructions from a recent appointment (include date of appointment, provider, & reason for appt):
Chronic/reoccurring health conditions requiring monitoring and treatment, as needed (migraines, asthma, ear infections, etc):
Describe any concerns for the child’s/youth’s development, or physical or behavioral health currently being monitored (ex: speech delay, possible food allergy, potential eating disorder, etc):
Current medications, including OTC:
Medication	Dosage/frequency	Reason
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Allergies – include type (ex: food, skin, pet, drug, etc), symptoms, treatments/action plans:
Significant, relevant medical/behavioral health history (illnesses, injuries, surgeries, etc):
Other helpful information to know about this child/youth – consider his/her emotional & physical safety, stability/anchors, social connections, etc:
Upcoming medical or behavioral health appointments:
Date/Time	Type	Provider/Clinic & Address	Reason
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If Other or Specialist, explain here:
Indicate any services or health care appointments that need to be arranged, and by when (ex: First Steps, immunizations, eye exam, etc)
Case Manager Signature	Date Provided to Resource Provider