All About Me YOUR NAME CHILD

All About Me YOUR NAME CHILD

Contents This is Me Page 3 This Is My Family Page 5 Emergency & Medical Contacts Page 7 Medical Information Page 10 Communication Page 12 I Like To Eat Page 13 Bedtime Page 15 My Daily Life Page 16 A day in my life looks like this: Page 18 Other Information Page 20

This is Me All About Me 3 My name is: I am years old. My birthday is on: The school I go to is: My teacher s name is: These are some pictures of me: Place your photo here Place your photo here Place your photo here

4 All About Me My favourite people and things are (for example, friends, pets, books, etc.): My favourite places are (for example, home, park, community centre):

This is My Family All About Me 5 These are the people who live in my home: Your Mom s photo Your Dad s photo My Mom s name is: My Dad s name is: These are the names of other people who live with me: brother sister other brother sister other brother sister other brother sister other brother sister other brother sister other

6 All About Me Here are photos of some of the people who live with me: Photo here Photo here Names: Names: Photo here Photo here Names: Names:

All About Me 7 Emergency & Medical Contacts Emergency Contact #1: Name: Relationship: Home: Work: Cell: Emergency Contact #2: Name: Relationship: Home: Work: Cell: Emergency Contact #3: Name: Relationship: Home: Work: Cell: Parents/Guardians/Caregivers: Name: Home: Work: Cell: Name: Home: Work: Cell:

8 All About Me Health Card #: Family Doctor Name: Phone Number: Family DENTIST Name: Phone Number: specialists Name: Phone Number: Name: Phone Number: Name: Phone Number:

All About Me 9 pharmacy Name: Phone Number: 911 service is is not available in my area If not, please list: Preferred Hospital: Phone: Address: Other Emergency Numbers (If applicable) Ambulance: Poison Control Centre: Police: Fire: Other Agencies I am Involved With: Agency Contact Person Phone #:

10 All About Me My Medical Information My tells me that my diagnosis is Medications: 1. Name of Medication: Dosage: When it should be taken: Reason I take it: 2. Name of Medication: Dosage: When it should be taken: Reason I take it: 3. Name of Medication: Dosage: When it should be taken: Reason I take it: 4. Name of Medication: Dosage: When it should be taken: Reason I take it: I require support in taking my medication: Yes No My medication is usually taken by I prefer my medication to be (crushed, with juice, etc.) Special instructions/ precautions for giving medication to me: I am allergic to: (medication, food, environmental) Please explain:

All About Me 11 Date of my last doctor s appointment: My immunizations are up to date: Yes No My Vision: My Hearing: My Mobility: My Respiratory: My Skin Care: I experience seizures: Yes (explained below) No Details about my seizures (triggers, frequency, etc.): Absence (Petit Mal): Tonic-Clonic (Grand Mal): Complex-Partial (Psycho Motor): The support I require during and following a seizure is: Other medical information you should know about me: (conditions, contagious diseases, equipment, supplies, support needs)

12 All About Me I communicate: Communication Method always sometimes never Comments by using words: by using signs: by using bliss/pecs: by using gestures/: facial expressions More information about how I communicate: If I need or want something, I will let you know by: My special words, signs, gestures are: When you are communicating with me, I need you to: Method always sometimes never Comments Make eye contact: Use smaller sentences: Control your tone of voice: Use gestures/ facial expressions: Use signs/pecs/bliss: Other information about Me

I Like to Eat All About Me 13 Things that I can make or get for myself are: (i.e., coffee, tea, cereal and meals): I need assistance to prepare: Breakfast Foods: Time: Lunch Foods: Time: Dinner Foods: Time: Snacks: Times: Types: I need assistance to eat: Yes No

14 All About Me You can help me eat by: I need special equipment to eat: Yes No Details: Some foods I eat require special preparation. (i.e. mashed, pureed, cut up finely) Length of time it takes me to eat: I (am) (am not) prone to choking spells. Foods I should not eat and why: BEVERAGES I LIKE: (I need to use a straw: Yes No) Milk Juice Coffee Chocolate Milk Pop Tea Hot Chocolate Water Other SNACKS I ENJOY: Potato Chips Raisins Ice Cream Yogourt Cookies Nuts Pudding Fruit Candy Crackers Jello Gum Cereal Cheese Apple Sauce Chocolate Other

Bedtime All About Me 15 I usually go to bed at, and I usually wake up at in the morning. I wake up at night. always / sometimes / almost never / never If I do wake up it is usually for I (require) (do not require) assistance during the night. When I do require assistance it will be for I (need) (do not need) repositioning during the night. I sleep in a (bed) (bed with rails). I like to have my bedroom door and the light. open / shut on / off Other helpful things to know, (number of blankets, pillow, nightlight, toys, etc):

16 All About Me My Daily Life When I m getting dressed, I can do everything on my own: Yes No You can help me by: When I need to go to the bathroom I will: Go by myself: Yes No Let you know by: Need your assistance with: I wear: Underwear Diapers Pullups Briefs And extras can be found: When it comes to personal hygiene, I am totally independent: Yes No I need some help: Bathing: Yes No Comments: Washing hands and face: Yes No Comments: Brushing teeth: Yes No Comments: Combing/Brushing hair: Yes No Comments: Feminine Hygiene: Yes No Comments: Other: Yes No Comments: During the day I like to have a rest/nap: Yes No Time: Place:

All About Me 17 My Recreation Life: My favourite toys and games are: My favourite activities are: My favourite sports are: My favourite places to go are: My favourite people to get together with are: My favourite TV programs are: It is preferred that I not watch: Other things I enjoy:

18 All About Me Feelings The things that make me happy are: The things that make me sad are: The things that make me upset/angry are: Sometimes I am afraid: You can help me with this by:

All About Me 19 A day in my life looks like this: 6:30 7:00 7:30 8:00 8:30 9:00 10:00 10:30 11:00 12:00 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30 7:00 7:30 8:00 8:30 9:00 9:30 10:00

20 All About Me Other Information:

Haliburton, Kawartha, Peterborough, Northumberland Northumberland Famly Respite Services Inc. Host Agency: Northumberland Family Respite Service Inc. 72 Walton Street Port Hope, On L1A 1N3 Phone: 905-885-6671 ext. 227 Fax: 905 885-9758 email: respiteservices.com@northumberlandfamilyrespite.ca