Synagis Referral Form 2007-2008 printable pdf download

**Synagis Referral Form 2007-2008**

Patient Name:________________________________

DOB:________________

SSN: __________________________________ Born at:____________weeks EGA

Parent Mailing Address:_____________________ __________________________

_____________________________________________________________________

Parent Home Phone:____________________Parent Cell Phone:_______________

Referring Provider:_________________________Birth Weight _____________KG

Risk Factors for this patient include (please check all that apply):

□ Born < 29 weeks and born after 1 November 2006 (less than 1 year of age at start of RSV season)

□ Born at 29 to 32 weeks and born after 1 May 2007 (less than 6 months of age at start of RSV season)

□ Born at 32+1 to 35+0 weeks and born after 1 May 2007 (less than 6 months of age at start of RSV season AND

has TWO or more of the following risk factors:

□ Child care attendance

□ School aged siblings

□ Exposure to environmental air pollutants (including tobacco smoke)

□ Congenital anomalies of the airways (specify__________________)

□ Severe neuromuscular disease (specify_______________________)

□ Birthweight < 2500 gms

□ Multiple birth (twin, triplet, quad etc.)

□ Not breast feeding

□ Less than 2 years of age with Chronic Lung Disease who currently require medical therapy for CLD or have

received medical therapy for CLD in the previous 6 months, (including single of combination of oxygen,

diuretics, daily inhaled steroids, scheduled bronchodilators)

□ Cardiac Risk factors in children under 24 months of age with congenital heart disease:

□ Hemodynamically significant acyanotic or cyanotic heart disease (especially those who are receiving medications

for congestive heart failure, who have moderate to severe pulmonary hypertension, or are undergoing cardiac

surgery during RSV season). Please specify disorder:

___________________________________________________________________________________________

□ Immunodeficiency (SCIDS, AIDS) – receiving regular IGIV infusions. Consider giving Synagis during RSV

season. To be reviewed by Pediatric Infectious Disease for risk analysis.

□

This patient doesn’t fit any of the above categories, but may benefit from Synagis prophylaxis. Describe

patient’s medical problems that increases risk for severe RSV lower respiratory tract

infection:___________________________________________________________________________________

___________________________

______________________________________________________________

Synagis Referral Form 2007-2008