Sick Kids'
Family Journal
Working together – sharing all that we know
This Journal belongs to
© 2000
555 University Avenue, Toronto, ON, Canada M5G 1X8
Sick Kids’ Family Journal
How to Use Your Sick Kids’ Family Journal
✰ What is the Sick Kids’ Family
Journal?
The Sick Kids’ Family Journal is
an easy-to-use diary in which you
record important information
about your child’s health. The
Journal belongs to your family. It
is up to you how much to include
in the Journal, and how to use the
information you record.
✰ How can the Sick Kids’ Family
Journal help you?
Finding your way around the
health care system can be very
confusing. Often different
people, in different settings, care
for your child. The Sick Kids’
Family Journal will help you
keep track of your child’s health
information and any questions
you may have. This will make it
easy for you to find and share
important information with all
members of your child’s health
care team.
✰ Who can read your Sick Kids’
Family Journal?
Your Journal belongs to your
family. Who sees it is up to you.
You may choose to share some or
all of it or you may keep it
private.
✰ How do I get more pages for my
Sick Kids’ Family Journal?
You can get more pages from:
✔ CHIP - Sick Kids main floor
✔ The hospital wards and
clinics
✔ from the Internet at
www.sickkids.on.ca
✰ Helpful Hints for using the Sick
Kids’ Family Journal
✔ Add new information to your
Journal whenever there is a
change in your child’s health
care.
✔ Encourage your child to add
comments or pictures to the
Journal.
✔ Siblings are also encouraged
to add comments or pictures
to the Journal.
✔ Take your Journal with you
to all appointments, both in
the hospital and in your
community.
✔ Regularly review your
Journal and take out
information that is not needed
anymore. Keep this
information somewhere
where you can find it if you
need it.
✔ Use the Journal in your own
way. Feel free to take out any
pages that are not appropriate
to your child’s health care.
The 3 - ring binder allows
you to easily add more pages
or sections that meet your
family’s needs.
Cover designed by:
Robert Murray of Robert A. Murray
Graphics Inc.
519-448-4719 or [email protected]
Robert’s child receives care at Sick Kids.
Adapted from the Care Notebook,
Children’s Hospital & Regional Medical
Center, Seattle, WA
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Personal Information
Personal Information
Child’s Name:
Date of Birth: Y
M
D
HSC Number:
Other Hospital Numbers: Hospital Name:
Preferred name:
Health Card Number:
Card Number:
Family Members
Parent/
Guardian
Parent/
Guardian
Parent/
Guardian
Name:
Relationship to Child:
Address:
Phone: Home:
Fax:
Work:
email:
Cell:
Name:
Relationship to Child:
Address:
Phone: Home:
Fax:
Work:
email:
Cell:
Name:
Relationship to Child:
Address:
Phone: Home:
Fax:
Work:
email:
Cell:
Other Household Members:
Name
Date of Birth
Relationship to Child
Important Family Information:
Preferred Language:
Other Languages spoken:
Interpreter’s Name:
Phone:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Medical History/Allergies
Brief Medical History (Diagnosis, Date):
Allergies
Remember to include all allergies: Medication, Food, Latex, Other
Allergy
Reaction (vomiting,
Treatment
Comments
hives, swelling etc.)
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Childhood Illnesses/Immunizations
Childhood Illnesses:
(Chicken Pox, Measles, Mumps, Rubella, Whooping Cough, etc.)
Childhood
Illness
Age Date of
Diagnosis
Y
M
Comments and Name of person making
diagnosis
D
Immunizations/Vaccination Record
You may already have this information on a Yellow Card given to you by your Family
Physician. Place a check mark in the box and fill in the date when your child receives the
immunization.
Date of
Vaccination
Y
M
Age
Recommended DTaP
Age at
Vaccination
Hib
MMR
Td
Hep B
(3 doses)
Other
D
2 months
DTaP
Hib
MMR
Td
Hep B
Other
Polio
Infancy or
preadolescence
(9-13 yrs)
4 months
6 months
12 months
18 months
4-6 years
14-16 years
every 10 years
Diphtheria, tetanus, pertussis vaccine
Haemophilus influenzae type b vaccine
Measles, mumps and rubella vaccine
Tetanus and diphtheria toxoid, “adult type”
Hepatitis B vaccine
May include flu shots, chicken pox vaccination, vaccines required for travel etc.
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
My Doctors
Medical Members of My Health Care Team (doctors, dentists, orthodontists, etc.)
• Paediatrician/Family Doctor
Name:
Address:
Phone:
email:
Fax:
• Doctor
❑ HSC
Name:
Office Phone:
Clinic Phone:
email:
❑ Other Hospital ❑ Community
Specialty:
Fax:
Clinic Day:
• Doctor
❑ HSC
Name:
Office Phone:
Clinic Phone:
email:
❑ Other Hospital ❑ Community
Specialty:
Fax:
Clinic Day:
• Doctor
❑ HSC
Name:
Office Phone:
Clinic Phone:
email:
❑ Other Hospital ❑ Community
Specialty:
Fax:
Clinic Day:
• Doctor
❑ HSC
Name:
Office Phone:
Clinic Phone:
email:
❑ Other Hospital ❑ Community
Specialty:
Fax:
Clinic Day:
• Doctor
❑ HSC
Name:
Office Phone:
Clinic Phone:
email:
❑ Other Hospital ❑ Community
Specialty:
Fax:
Clinic Day:
• Doctor
❑ HSC
Name:
Office Phone:
Clinic Phone:
email:
❑ Other Hospital ❑ Community
Specialty:
Fax:
Clinic Day:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
More Members of My Team
More Members of My Health Care Team (HSC and the Community)
Think about including your social worker, child life specialist, dietitian, discharge planner, occupational therapist, physical therapist,
speech-language pathologist, clinic nurse, nurse practitioner, pharmacist, home nursing agency, contact person, etc.
Name:
Specialty:
Office Phone:
Address:
❑ HSC ❑ Other Hospital ❑ Community
Organization Name:
Fax:
email:
Name:
Specialty:
Office Phone:
Address:
❑ HSC ❑ Other Hospital ❑ Community
Organization Name:
Fax:
email:
Name:
Specialty:
Office Phone:
Address:
❑ HSC ❑ Other Hospital ❑ Community
Organization Name:
Fax:
email:
Name:
Specialty:
Office Phone:
Address:
❑ HSC ❑ Other Hospital ❑ Community
Organization Name:
Fax:
email:
Name:
Specialty:
Office Phone:
Address:
❑ HSC ❑ Other Hospital ❑ Community
Organization Name:
Fax:
email:
Name:
Specialty:
Office Phone:
Address:
❑ HSC ❑ Other Hospital ❑ Community
Organization Name:
Fax:
email:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Equipment and Supplies
Equipment and Supplies
• Equipment:
Description (brand name, size, etc.):
Supplier:
Contact Person:
Address:
email:
• Equipment:
Description (brand name, size, etc.):
Supplier:
Contact Person:
Address:
email:
• Equipment:
Description (brand name, size, etc.):
Supplier:
Contact Person:
Address:
email:
• Equipment:
Description (brand name, size, etc.):
Supplier:
Contact Person:
Address:
email:
• Equipment:
Description (brand name, size, etc.):
Supplier:
Contact Person:
Address:
email:
• Equipment:
Description (brand name, size, etc.):
Supplier:
Contact Person:
Address:
email:
Phone:
Phone:
Phone:
Phone:
Phone:
Phone:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Care Log
This section may be used to keep track of your child’s admissions, treatments, surgeries, tests and procedures (i.e. X-rays, CT Scans, MRIs,
ECGs etc.)
Date
Responsible
Doctor
Hospital/Ward or
Clinic
Reason for Visit (surgery,
test, procedure, treatment)
Comments/Outcomes/Discharge
Plans/Instructions
Corresponding
Blood Work/
Test Results in
Next Section
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
❏ Yes
❏ No
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Blood Work and Test Results
Date
Who ordered the test?
Test
Results and Comments
Name and Specialty
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Prescribed Medications
Medicine Ordered By Health Care Professional
*Name and
strength of
medicine
Who prescribed
the medicine?
Name and Specialty
What is the
medicine for?
Amount given
at each dose
Number of
times given
every day
Comments
(how your child takes it, reactions etc.)
Start
Date
Finish
Date
*Medications often have more than one name. Include all the names you know.
Medications come in different strengths. Please include the strength of your child’s medication when filling in this chart. For example: 1 teaspoon of Tylenol 80 milligrams per milliliter is different than 1
teaspoon of Tylenol 160 milligrams per milliliter
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Over-the-counter Medications/Remedies
Occasional Medicine and Complementary or Alternative Remedies (i.e. Tylenol, Vitamins, Cough Syrup, Echinecea etc.)
Name and
strength of
medicine/
remedy
Did someone
recommend the
medicine? If
yes, who?
What is the
medicine for?
Amount given
at each dose
Number of
times given
every day
Comments
(how your child takes it, reactions etc.)
Start
Date
Finish
Date
Name and Specialty
*Medications come in different strengths. Please include the strength of your child’s medication when filling in this chart. For example: 1 teaspoon of Tylenol 80 milligrams per milliliter is different than 1
teaspoon of Tylenol 160 milligrams per milliliter
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Through My Eyes…
The “Through My Eyes…” section was created to encourage you and your child to express your
personal thoughts and feelings. Once filled out, these sheets may help health care professionals to
better understand how to meet your child’s and families’ needs.
There are separate pages for children, parents and siblings.
If your child is too young to fill in the pages, you may want to complete their pages for them. The
pages were designed to allow your child to draw pictures if they cannot write.
Other parents have found these pages most useful when their child is in the hospital. They fill in
the pages and hang them on the wall in their child’s hospital room. The sheets may be useful in
helping others care for your child if you are unavailable.
You may have to redo this section each time your child is admitted to the hospital as your child’s
needs and your needs may change as your child grows.
The blank pages at the end of this section are called “My Thoughts & Questions”. Your family
can record their thoughts, observations, events, and questions in this section.
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
My Page
Today’s date is:
The name I like to be called is:
I am ______ years old. My birthday is__________________.
I like:
I don’t like:
Foods
Toys/games
TV shows/movies
Books
Music
More things I want people to know about me are:
If I had three wishes, I would wish for:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
My Page
Draw or write your answers to the following questions.
Things that make me happy are:
I show happiness by:
Things that make me sad are:
I show sadness by:
Things that comfort me are:
I show I am comforted by:
Things that make me angry are:
I show I am angry by:
Things that make me scared are:
I show I am scared by:
Things that worry me are:
I show I am worried by:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Parent/Guardian Page
Today’s date is:
The name I (parent/guardian) prefer to be called by the members of the health care team is:
My schedule is:
My child’s schedule at home is:
My child needs help with:
My child’s feeding routine is:
My child’s bathing routine is:
My child’s sleeping routine is:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Parent/Guardian Page
Special words our family uses are:
(Include special words for body parts, pain, foods, etc.)
My child lets you know how they are feeling or thinking by:
Things that upset my child are:
When my child is upset, things that help are:
Other important things that help me and my family are:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Brother/Sister Page
Today’s date is:
The name I like to be called is:
I am _____ years old. My birthday is _______________.
My schedule is:
I like:
I don’t like:
Foods
Toys/games
TV shows/movies
Books
Music
The best thing about visiting the hospital is:
The worst thing about visiting the hospital is:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Brother/Sister Page
Draw or write your answers to the following questions.
Things that make me happy are:
I show happiness by:
Things that make me sad are:
I show sadness by:
Things that comfort me are:
I show I am comforted by:
Things that make me angry are:
I show I am angry by:
Things scare me are:
I show I am scared by:
Things that worry me are:
I show I am worried by:
If I had three wishes, I would wish for:
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Thoughts & Questions
Your family can record their thoughts, observations, events etc. in this section. It may be
useful to date your entries.
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Research Participation
You may be asked to participate in research studies while your child is at Sick Kids. This
form will allow you to keep a record of the research your child is involved in.
Date
Title of Research
Project
Reason for
Research
Name and Phone
Number of
Research Contact
Person
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Other Information
Parent Guidebook
The HSC Parent Guidebook contains information that may be helpful while you
are at Sick Kids. In the Guidebook you will find maps, important phone numbers,
areas of interest in the hospital and tips about making your stay more comfortable.
If you do not have a Parent Guidebook, please ask any hospital employee to get
you one.
The Centre for Health Information and Promotion (CHIP)
The Centre for Health Information and Promotion (CHIP), located on the main
floor (m296) is open Monday to Friday (9:30 - 3:30) and has medical, health,
safety and child-raising information. CHIP also has a parent workstation which
will enable access to the following services: Internet and email access, lap top port
connection, fax machine to send or receive faxes, and a bell telephone with credit
care access to make long distance calls.
Hospital Costs
While your child is in hospital, medical and surgical costs are covered by your
provincial health insurance plan; OHIP (Ontario Health Insurance Plan) in
Ontario. However, a number of costs are not covered by OHIP. While your child
is a patient you are responsible for: transportation, parking, long distance phone
calls, meals for parents, child care for others in the family and accommodation for
a parent who is not staying in the child’s room.
When your child is discharged, the following ongoing costs may also become your
responsibility: drugs, equipment, transportation, nursing care in the home,
ongoing clinic visits, respite care, dietary needs, specialized day care, extra
clothing etc.
Many resources exist which may help you to pay for other costs, However, the list
is long and some only cover specific types of costs. For more information about
which resources may be appropriate to cover your needs, talk to your discharge
planner or social worker on the unit. You may call the departments directly:
Discharge Planning - (416) 813-5009
Social Work - (416) 813-6805
Centre for Health Information and Promotion - (416) 813-6528
© 2000 The Hospital for Sick Children, Toronto, Canada
Sick Kids’ Family Journal
Make-a-Calendar
Create your own calendar. Simply put the month and year on the line and fill in the boxes with
the date. Then use the calendar to keep track of important dates and appointments.
Month_____________ Year______________
Monday
Tuesday
Wednesday
Thursday
Friday
Sat/Sun
Thursday
Friday
Sat/Sun
Month_____________ Year______________
Monday
Tuesday
Wednesday
© 2000 The Hospital for Sick Children, Toronto, Canada