Pedia: ER Referral -> ER Phone

Name:
Age/Sex:
AMD:
BDAY:
ADDRESS:
WEIGHT:
LENGTH :
Mothers Name:
Fathers Name :
Contact # :

CC:

HPI:

Last Vomiting:
Last BM:
Last UO:
Last Febrile Episode:
Last Para:

PMH
Prev surgeries/hospitalizations:
(-)Prev hosp
(-) Allergies
(-) Surgeries:
(-)Asthma
(-) Allergic Rhinitis
(-) Other:

Family History:

Vaccination History: Complete

PSH: Patient lives in a ____ with _ and does not live with smokers. Member in the
household is vaccinated against COVID. Drinking water is _ water. Garbage disposal
collected everyday. Father works as a _. Mother works as a sales _. No recent
travel. No exposure to people with cough and colds.

NH: Patient eats 3x a day with snacks in between, with no food apreference. Water
source is distilled water. Decrease in appetite since the start of the subjective
complaints.

Maternal Hx:
Born to a _ years old G1 P0 (0000) via LTCS due to - in _ patient was admitted to _
for - hours for observation but was then discharged with no problem.

O>
T HR RR O2 at RA
Awake, Cooperative, not in respiratory distress
Pink palpebral conjunctiva, anicteric sclerae
Nonhyperemic PPW, moist lips and moist buccal mucosa
Adynamic precordium, normal rate regular rhythm,
Symmetrical chest expansion, clear breath sounds
Abdomen soft, flat, nontender abdomen on all quadrants
No bipedal edema, CRT <2s, full and equal pulses
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P>
Admitting Orders:
-
______________