Emergency Information Form For Children With Autism Form - American Academy Of Pediatrics
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1
2Emergency Information Form for Children With Autism
Date form
Revised
Initials
completed
Revised
Initials
By Whom
Name:
Birth date:
Nickname:
Home Address:
Home/Work Phone:
Parent/Guardian:
Emergency Contact Names & Relationship:
Signature/Consent*:
Primary Language:
Phone Number(s):
Primary Means of Communication:
Does s/he wear a medical ID bracelet?
Physicians:
Primary care physician:
Emergency Phone:
Fax:
Current Specialty physician:
Emergency Phone:
Specialty:
Fax:
Current Specialty physician:
Emergency Phone:
Specialty:
Fax:
Additional Specialty physician:
Emergency Phone:
Specialty:
Fax:
Anticipated Primary ED:
Pharmacy:
Anticipated Medical Center:
Diagnoses/Past Procedures/Physical Exam:
1.
Baseline vital signs:
Most recent height and weight (date):
2.
3.
Baseline neurological status:
Estimated age equivalent (date) for:
4.
Receptive language:
Expressive language:
Synopsis:
Cognitive skills:
Gross motor skills:
Fine motor skills:
Baseline physical findings:
Comfort items:
Does s/he tend to wander off?
Where to?
*Consent for release of this form to health care providers
Adapted from the ACEP/AAP Emergency Information Form for Children with Special Needs
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