Emergency Information Form For Children With Autism Form - American Academy Of Pediatrics Page 2
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1
2Diagnoses/Past Procedures/Physical Exam continued:
Medications:
Significant baseline ancillary findings (lab, x-ray, ECG):
1.
2.
3.
4.
5.
6.
Management Data:
Allergies: Medications/Foods to be avoided
and why:
1.
2.
3.
Procedures to be avoided
and why:
1.
2.
3.
Immunizations (mm/yy)
Dates
Dates
DTaP
Hep B
IPV
Varicella
MMR
TB status
HIB
Influenza
Tdap
Pneumococcus
Hep A
Meningococcus
HPV
Rotavirus
Antibiotic prophylaxis:
Indication:
Medication and dose:
Common Presenting Problems/Findings With Specific Suggested Managements
Problem
Suggested Diagnostic Studies
Treatment Considerations
Comments on child, family, or other specific medical issues:
Physician/Provider Signature:
Print Name:
Adapted from the ACEP/AAP Emergency Information Form for Children with Special Needs
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