Bleeding Disorder Care Plan

Student Name:*
Grade:*
Teacher:
Date of Plan:*
MM slash DD slash YYYY
Parent/Guardian Contacts
Parent/Guardian 1 Name:*
Relationship:*
Contact Number:*
Parent/Guardian 2 Name:
Relationship:
Contact Number:
Emergency Contact Name:*
Relationship:*
Contact Number:*
Hemophilia Treatment Center Contact Name:
Hemophilia Treatment Center Contact Number:
Bleeding Disorders
Haemophilia A (Factor VIII Deficiency)
- Haemophilia A (Factor VIII Deficiency)
Haemophilia A
- Server
- Moderate
- Mild
Haemophilia B (Factor IX Deficiency)
- Haemophilia B (Factor IX Deficiency)
Haemophilia B
- Severe
- Moderate
- Mild
Von Willebrand Disease (VWD)
- Von Willebrand Disease (VWD)
Von Willebrand Disease
- Type I
- Type IIa
- Type IIb
- Type III
Other
Signs he/she is having a bleeding episode:
Signs he/she is having a bleeding episode:
- Says something hurts
- Warmth, swelling, redness in joint or muscle
- Unusual limb position
- No use of a limb
- Cranky, Irritable
- Bubbling or tingling in area affected
- Other
Other:
Treatment Plan
His/Her treatment plan for a MINOR bleeding episodes (see below for description) :
His/Her treatment plan for a MAJOR bleeding episodes (see below for description) :
Medication:
Medication Name:
Dosage:
Special Considerations:
Medication will be stored:
Arrangement for delivery to school:
He/She receives his/her factor medication/infusions via:
- Catheter ( med-a-port/ Port-a-cath, or Broviac/Hickman catheter)
- Intravenous infusion into vein
- Others
Others
Other particular needs/issues
Physical activities:
Plan for Absenteeism:
Notes:
Signature*
Email:*
Date*
MM slash DD slash YYYY

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Bleeding Disorder Care Plan

Parent/Guardian Contacts

Bleeding Disorders

Signs he/she is having a bleeding episode:

Treatment Plan

Medication:

Other particular needs/issues