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FILL-IN VERSION WITH SPACES FOR TYPING AND IMAGES Universal 2.0 Autism COVID-19 Individual Health Action Plan

FILL-IN VERSION WITH SPACES FOR TYPING AND IMAGES Autism COVID-19 Individual Health Action Plan Universal 2.0 Format In order to fill-in you need to download the file as a pdf and read with adobe reader or in your browser on a computer or laptop. Contents: SECTION ONE: Do I have any Symptom's of COVID-19 Am I in a priority group? My notes SECTION TWO: How I can contact my GP (Doctor) Who and How I contact people if I need help SECTION THREE: Your important information SECTION FOUR: How I communicate SECTION FIVE: Emergency Bag checklist in case I need to go to the hospital. Note. I am more than happy to make any specific Individual alteration as needed., e.g., specific visuals added or changed in graphics. please contact if needed. Contact Email: doylej30@tcd.ie Twitter: @JesscaDoyle Linkedin: linkedin.com/in/jessicakdoyle

FILL-IN VERSION WITH SPACES FOR TYPING AND IMAGES
Autism COVID-19 Individual Health Action Plan
Universal 2.0 Format

In order to fill-in you need to download the file as a pdf and read with adobe reader or in your browser on a computer or laptop.
Contents:
SECTION ONE:
Do I have any Symptom's of COVID-19
Am I in a priority group?
My notes

SECTION TWO:
How I can contact my GP (Doctor)
Who and How I contact people if I need help

SECTION THREE:
Your important information

SECTION FOUR:
How I communicate

SECTION FIVE:
Emergency Bag checklist in case
I need to go to the hospital.

Note. I am more than happy to make any specific Individual alteration as needed., e.g., specific visuals added or changed in graphics. please contact if needed.

Contact
Email: doylej30@tcd.ie
Twitter: @JesscaDoyle
Linkedin: linkedin.com/in/jessicakdoyle

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SECTION THREE:<br />

• Your important information<br />

Includes fillin<br />

sections<br />

___________<br />

My Full name is<br />

My Date of<br />

birth is:<br />

My gender is:<br />

My Personal Details<br />

Notes to filling form out are<br />

marked with a *<br />

* Put down first and last name.<br />

My Address is:<br />

My postcode is:<br />

I have a<br />

diagnosis of:<br />

My blood type<br />

is:<br />

*You can list previous diagnoses<br />

you have received from<br />

professionals.<br />

*Only write this down if you<br />

definitely know it, most people<br />

don’t and that’s okay.<br />

My GP’s (Doctor) Information<br />

List your GP’s (doctor) information below.<br />

My GP’s (doctor) name is:<br />

My GP’s (doctor) phone number<br />

My GP’s (doctor) address is:<br />

My emergency contacts information<br />

List your emergency contacts information below, this is also called “Next of kin” and is someone the<br />

doctors can contact for you if you are in an emergency.<br />

My Emergency contacts name is:<br />

My Emergency contacts phone:<br />

My Emergency contacts address<br />

is:<br />

Medication I take<br />

List your prescribed medication and over-the-counter medication, such as vitamins and inhalers that<br />

you take.<br />

(*Some people don’t take any medication so its not unusual to leave this blank.)<br />

Name the Drug Dosage Frequency Taken<br />

Medications I am allergic to<br />

List any medication you have had an allergic reaction to in the past.<br />

(*Lots of people are not allergic to any medication so its not unusual to leave this blank.)<br />

Name the Drug<br />

Reaction You Had<br />

<strong>Autism</strong> <strong>COVID</strong>-<strong>19</strong> <strong>Individual</strong> <strong>Health</strong> <strong>Action</strong> <strong>Plan</strong>, created<br />

by Jessica K. Doyle, Ireland 2020<br />

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