information is unknown to me medical condition, but these interfering with treatment and her condition that is / does not apply. are not affecting other areas other areas of life. interfering with treatment of life. and functioning. If the needs / functioning fall within a shaded box, explain why: child’s III-11. Medical Needs Impairment in Functioning (PAST 30 DAYS) – medical condition is medical condition is medical condition is medical condition Child’s Child’s Child’s Child’s not interfering with his / her having a limited impact on interfering with functioning in has disabled him / her in all functioning in other areas of functioning in one area of life more than one area of life or other areas of life. life or this information is (self care, social interaction, is disabling in at least one unknown to me / does not communication, etc). domain. apply. If the needs / functioning fall within a shaded box, explain why: child’s C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages 5 to 21) (Continued) III-12. Medical Needs Treatment Involvement (PAST 30 DAYS) – Child is actively involved in Child is generally involved in Child is generally uninvolved Child is currently resistant treatment or this is not treatment but may struggle to although they are sometimes to all efforts to provide applicable or this information stay consistent. compliant with medical treatment. is unknown to me. recommendations. If the needs / functioning fall within a shaded box, explain why: child’s III-13. Medical Needs Intensity of Treatment (PAST 30 DAYS) – medical treatment medical treatment treatment is daily but medical treatment Child’s Child’s Child’s Child’s involves taking daily involves multiple non-invasive. Treatment can is daily and invasive and medications or visiting a medications or visiting a be administered by a requires either a medical medical professional no more medical professional multiple caregiver. professional or trained than weekly, or this times per week. caregiver to administer. information is unknown to me / does not apply. If the needs / functioning fall within a shaded box, explain why: child’s III-14. Medical Needs Organizational Complexity (PAST 30 DAYS) – All medical care is provided medical care is medical care requires medical care Child’s Child’s Child’s by a single medical generally provided by a collaboration of multiple requires the collaboration professional or this coordinated team of medical professionals who work for of multiple professionals
information is unknown to me / does not apply. medical condition, but these are not affecting other areas of life. interfering with treatment and other areas of life. her condition that is interfering with treatment and functioning. If the child’s needs / functioning fall within a shaded box, explain why: III-11. Medical Needs – Impairment in Functioning (PAST 30 DAYS) Child’s medical condition is not interfering with his / her functioning in other areas of life or this information is unknown to me / does not apply. Child’s medical condition is having a limited impact on functioning in one area of life (self care, social interaction, communication, etc). Child’s medical condition is interfering with functioning in more than one area of life or is disabling in at least one domain. Child’s medical condition has disabled him / her in all other areas of life. If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages 5 to 21) (Continued) III-12. Medical Needs – Treatment Involvement (PAST 30 DAYS) Child is actively involved in treatment or this is not applicable or this information is unknown to me. Child is generally involved in treatment but may struggle to stay consistent. Child is generally uninvolved although they are sometimes compliant with recommendations. Child is currently resistant to all efforts to provide medical treatment. If the child’s needs / functioning fall within a shaded box, explain why: III-13. Medical Needs – Intensity of Treatment (PAST 30 DAYS) Child’s medical treatment involves taking daily medications or visiting a medical professional no more than weekly, or this information is unknown to me / does not apply. Child’s medical treatment involves multiple medications or visiting a medical professional multiple times per week. Child’s treatment is daily but non-invasive. Treatment can be administered by a caregiver. Child’s medical treatment is daily and invasive and requires either a medical professional or trained caregiver to administer. If the child’s needs / functioning fall within a shaded box, explain why: III-14. Medical Needs – Organizational Complexity (PAST 30 DAYS) All medical care is provided by a single medical professional or this Child’s medical care is generally provided by a coordinated team of medical Child’s medical care requires collaboration of multiple professionals who work for Child’s medical care requires the collaboration of multiple professionals
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