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HomeMy WebLinkAbouteif-formEmergency Information Form for Children With Special Needs Name:Birth date: Nickname: Home Address: Home/Work Phone: Parent/Guardian: Emergency Contact Names & Relationship: Signature/Consent*: Primary Language: Phone Number(s): Physicians: Primary care physician: Emergency Phone: Fax: Current Specialty physician: Emergency Phone: Specialty: Fax: Current Specialty physician: Emergency Phone: Specialty: Fax: Anticipated Primary ED: Pharmacy: Anticipated Tertiary Care Center: Diagnoses/Past Procedures/Physical Exam: 1 . 2. 3. 4. Synopsis: Baseline physical findings: Baseline vital signs: Baseline neurological status: Date form completed By Whom Revised Initials Revised Initials La s t n a m e : *Consent for release of this form to health care providers Management Data: Allergies: Medications/Foods to be avoided and why: 1. 2. 3. Procedures to be avoided and why: 1. 2. 3. Common Presenting Problems/Findings With Specific Suggested Managements Problem Suggested Diagnostic Studies Treatment Considerations Immunizations Dates DPT OPV MMR HIB Dates Hep B Varicella TB status Other Antibiotic prophylaxis: Indication: Medication and dose: Diagnoses/Past Procedures/Physical Exam continued: Medications: 1. 2. 3. 4. 5. 6. Significant baseline ancillary findings (lab, x-ray, ECG): Prostheses/Appliances/Advanced Technology Devices: Comments on child, family, or other specific medical issues: Physician/Provider Signature: Print Name: La s t n a m e : © American College of Emergency Physicians and American Academy of Pediatrics. Permission to reprint granted with acknowledgement.