This document contains forms for a caregiver to provide updates on a child's health, functioning, and wellbeing. The forms include sections to note things going well, areas that could be improved, and current concerns. For concerns, the caregiver rates general areas like health, mobility, and behavior on a traffic light system of green (no concerns), amber (some concerns), and red (serious concerns). The purpose is to help guide discussion in a medical consultation and create an action plan to address any issues.

1. Name of child: DoB: Age: Date completed:
HEALTH, FUNCTIONING AND WELLBEING UPDATE
Please fill in this information. It will help to make best use of consultation time, to cover all of the
things that are important for you. The clinic letter you receive will reflect the contents with the
action plans completed. You can then show it to any other health workers who need to see it.
Things to celebrate, things that are going well:
Thoughts about what might help to make it easier to join in everyday activities and make life more
enjoyable:
Things that are causing concern and questions:
karen.horridge@nhs.net 11 October 2011

2. Name of child: DoB: Age: Date completed:
For each of the following, please indicate which traffic light colour indicates your concerns the best.
GREEN = no concerns, all is well. AMBER = some concerns. RED = serious concerns.
No Some Serious Action plan
concerns concerns concerns
General health
Pain
Seizures (fits, faints, funny turns)
Frequent chest infections
needing antibiotics
Difficulties swallowing/chewing/
eating/drinking/drooling
Acidy burps, reflux or vomiting
Constipation (infrequent stools,
hard to pass)
Growth/weight gain/
physical development/puberty
Mobility, moving around
Hand function
Personal care
(feeding/washing/dressing/
toileting etc.)
Vision (eyesight)
Hearing
Speech and communication
Friendships and relationships
Behaviour, emotions and feelings
Learning
Sleep
Equipment issues
Family issues
Housing issues
School issues
Leisure issues
Other (please specify)
karen.horridge@nhs.net 11 October 2011