Forms

For Parents and Patients

AAP Emergency Form ( 112 KB)
This form helps parents record information for thier child including home address; physicians and specialists; diagnoses; procedures; allergies; medications; and more; from the American Academy of Pediatrics and the American College of Emergency Physicians.

AAP Build Your Own Care Notebook
The American Academy of Pediatrics provides a central place with links to nearly 50 types of forms from many states. Families can pick a type of form or topic (such as Care Providers) and then pick a state (such as UT) to view or download that form in Word or PDF formats. Each state may provide different suggestions for what information families might want to track about the care of their children. For families that are new to making care notebooks, we suggest you pick one form (such as Medications) and try filling it out before downloading other forms.

Emergency Health Information System
This link to the Utah Emergency Medical Services for Children (EMSC) web site contains an online form for CSHCN that can be filled out by parents, placed in a provided tube, and placed in the main fridge of the home. This allows emergency medical service (EMS) providers to quickly find medical information and provide immediate care, before they reach the hospital, for children with complex medical conditions in the event of an emergency or disaster.

Emergency Information Sheet Utah
This form, for use by Utah emergency medical services, helps parents record information for thier child including diagnoses; procedures; allergies; medications; and more; from the Utah Department of Health, Utah Family Voices, and Utah Collaborative Medical Home Project.

Emergency Information Sheet Utah, Page 3
Page 3 of the form, for use by Utah emergency medical services, that helps parents record information for thier child including diagnoses; procedures; allergies; medications; and more; from the Utah Department of Health, Utah Family Voices, and Utah Collaborative Medical Home Project.

Special Needs Registry
This registration website allows residents with special needs an opportunity to provide information to emergency response agencies so those agencies can better plan to serve them in a disaster or other emergencies. Provided by United Way of Northern Utah, Utah 211, Utah Citizen Corps, and the Utah Department of Public Safety.

Find and Apply for State Services in Utah
Utah Clicks provides online applications to Utah Programs including Baby Watch Early Intervention, Baby Your Baby, Head Start, Early Head Start, and Children with Special Health Care Needs (CSHCN).

Release of Information Form (Medical) ( 28 KB)
This sample form may be used to share information between designated providers. Check with your Medical Home for more information.

Tracking Medical Bills ( 125 KB)
This form, developed for Tennessee's Family Information Notebook, provides a way to track bills including dates, insurance company, who paid, and more. For a PDF version and other forms, see the Care Notebook page.

Weekly Medication Diary ( 99 KB)

All About Me ( 110 KB)
This 31-page transition notebook for teens has forms for infomation including emergency contact; providers; personal and family history; insurance; appointments; and medications. The first page has a place to put your picture and the last few pages have a brief listing of suggested state (Okalahoma) and national resources.

All About Me ( 415 KB)
This 31-page transition notebook for teens has forms for infomation including emergency contact; providers; personal and family history; insurance; appointments; and medications. The first page has a place to put your picture and the last few pages have a brief listing of suggested state (Okalahoma) and national resources.

Portable Medical Summary ( 70 KB)
A 2-page form to keep track of medical information including diagnoses, medications, equipment, hospitalizations, and insurance.