PARENT/GUARDIAN ACTION FORM MIDDLE TRANSITION (14-16 years) MY CHILD’S NAME: _____________________________________________ DOB: _________________ DATE:______________________ DOMAINS/GOALS STRATEGIES TO ACHIEVE GOALS COMPLETED TRANSPLANT KNOWLEDGE My child is able to state why he had a transplant. I have talked to my child about his health history and the reason for transplant. My child has a basic understanding of what rejection means. My child understands why it is important to get his labs routinely. My child and I have discussed what it means to have rejection, how the healthcare provider knows if there is rejection, how it is treated and why his labs are important in monitoring his health. My child understands that he can discuss questions and concerns about transplant with his healthcare providers. MEDICATIONS My child can state the names of all his medications, the reason he takes them, the dose and the times he takes them. My child keeps a list of his medications with him (phone, wallet, other). My child knows the name of our pharmacy and is learning how to contact the pharmacy when he needs medication refills. I am helping my child learn about his medications. I have helped my child make a list of his medications. I have helped my contact the pharmacy to order refills of his medications. ADHERENCE My child independently takes his medications every day and on time. My child knows how often he is supposed to get his labs. I am helping my child understand why it is important to take his medications every day and on time and get labs as requested. I am giving my child increasing responsibility for taking medications with the goal of being independent in taking medications. I am helping my child develop a routine for taking his medications. I am encouraging him to remember on his own and to participate by filling his med container and being aware when he is running low on medications. RISK-TAKING BEHAVIORS My child knows that risk-taking behaviors (smoking, drinking, taking street drugs) are of more concern for him because he had a transplant. My child and I discuss how risk-taking behaviors can be harmful to his health and the health of the transplanted organ.
PARENT/GUARDIAN ACTION FORM MIDDLE TRANSITION (14-16 years) MY CHILD’S NAME: _____________________________________________ DOB: _________________ DATE:______________________ DOMAINS/GOALS STRATEGIES TO ACHIEVE GOALS COMPLETED TRANSPLANT KNOWLEDGE My child is able to state why he had a transplant. I have talked to my child about his health history and the reason for transplant. My child has a basic understanding of what rejection means. My child understands why it is important to get his labs routinely. My child and I have discussed what it means to have rejection, how the healthcare provider knows if there is rejection, how it is treated and why his labs are important in monitoring his health. My child understands that he can discuss questions and concerns about transplant with his healthcare providers. MEDICATIONS My child can state the names of all his medications, the reason he takes them, the dose and the times he takes them. My child keeps a list of his medications with him (phone, wallet, other). My child knows the name of our pharmacy and is learning how to contact the pharmacy when he needs medication refills. I am helping my child learn about his medications. I have helped my child make a list of his medications. I have helped my contact the pharmacy to order refills of his medications. ADHERENCE My child independently takes his medications every day and on time. My child knows how often he is supposed to get his labs. I am helping my child understand why it is important to take his medications every day and on time and get labs as requested. I am giving my child increasing responsibility for taking medications with the goal of being independent in taking medications. I am helping my child develop a routine for taking his medications. I am encouraging him to remember on his own and to participate by filling his med container and being aware when he is running low on medications. RISK-TAKING BEHAVIORS My child knows that risk-taking behaviors (smoking, drinking, taking street drugs) are of more concern for him because he had a transplant. My child and I discuss how risk-taking behaviors can be harmful to his health and the health of the transplanted organ.
Parent%20Action%20Form_Mid%20Adol_APR2017.docx