Child's Full Name
Child's Address
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Age of child? less than 1 yrs old onetwothreefourfivesixseveneightnineteneleventwelvethirteenfourteenfifteensixteenseventeeneighteengreater than eighteen Birthdate Weight (lbs) Sweatshirt size smallmediumlargeX-largeXX-large
Child's Diagnosis Parent Name Phone: Parent Name Phone:
Home Equipment (please list brand name of equipment) Apnea monitor Portable Suction Oxygen Compressor Tube feeding pump Oxygen Saturation Monitor Home Suction Type of portable oxygen If other, please specify:
Community Care Providers Home care case manager: Phone: Respiratory Care: Phone: Home care agency: Phone: Pediatrician: Phone:
Special Care Needs
Respiratory Status Bedside Mode Rate IT/FR Set Vt Exh. Vt Hi/Lo Alarm PIP/Peep FIO2 Chair Mode Rate IT/FR Set Vt Exh. Vt Hi/Lo Alarm PIP/Peep FIO2 BiPAP Mode IPAP EPAP BPM %IPAP FIO2 Mask Size/Brand Head Gear Support Hours ON OFF SpO2/ETCO2(normal range) O2 when off vent/device Speaking valve/cap Trach Tube Brand Size Cuff Fenestration Inner Cannula Cuff Pressure/cc's air Hours of inflation/deflation Freq. of Trach change Difficulty(Scale of 1-5; 1=Easy and 5=Hard) Suction catheter type/size Frequency of suction Respiratory Treatments Medications Frequency/times P & PD frequency/times Does child require oral or NP suctioning if not trached?
Elimination Voiding Pattern Voluntary Diapers CIC Times/day Catheter type Size Bowel Pattern Voluntary Diapers Bowel Program
Mobility Ambulatory Non-Ambulatory Ambulation with Manual Wheelchair Electric Wheelchair Bed Hospital bed Regular bed Crib Special mattress Turns self Turn everyhours
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