Emergency Information Form for Children With Special Needs 

American College of Emergency Physicians

American Academy of Pediatrics

DELAWARE HEALTH AND SOCIAL SERVICES
Division of Public Health
Office of Emergency Medical Services

Date form 	Revised 	Initials 
completed 
By Whom 	Revised 	Initials


Name:__________________________________________ Birth date:_______________ Nickname:_________________________

Home Address:______________________________________________________ Home/Work Phone:_________________________

Parent/Guardian:________________________________________ Emergency Contact Names & Relationship:_____________

Signature/Consent*:_____________________________________ ____________________________________________________

Primary Language:_______________________________________ Phone Number(s):____________________________________

Physicians: 
Primary care physician:_____________________________________________ Emergency Phone:________________________

                                                                     Fax:____________________________________

Current Specialty physician:________________________________________ Emergency Phone:________________________

Specialty:__________________________________________________________ Fax:____________________________________

Current Specialty physician:________________________________________ Emergency Phone:________________________

Specialty:__________________________________________________________ Fax:____________________________________

Anticipated Primary ED:_____________________________________________ Pharmacy:_______________________________

Anticipated Tertiary Care Center:____________________________________________________________________________

Diagnoses/Past Procedures/Physical Exam: 

1.___________________________________________________ Baseline physical findings:____________________________

_____________________________________________________ _______________________________________________________

2.___________________________________________________ _______________________________________________________
 
_____________________________________________________ _______________________________________________________

3.___________________________________________________ Baseline vital signs:__________________________________

_____________________________________________________ _______________________________________________________

4.___________________________________________________ _______________________________________________________

Synopsis:____________________________________________ _______________________________________________________

_____________________________________________________ Baseline neurological status:__________________________

_____________________________________________________ _______________________________________________________

____________________________________________________ ________________________________________________________
*Consent for release of this form to health care providers
 

Diagnoses/Past Procedures/Physical Exam continued:
 
Medications:_________________________________________ Significant baseline ancillary findings(lab, x-ray, ECG): 

1.___________________________________________________ ________________________________________________________

2.___________________________________________________ ________________________________________________________

3.___________________________________________________ ________________________________________________________

4.___________________________________________________ Prostheses/Appliances/Advanced Technology Devices:______

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 
DPT   ________ ________ ________ ________ ________	Hep B      ________ ________ ________ ________ ________
OPV   ________ ________ ________ ________ ________ 	Varicella  ________ ________ ________ ________ ________
MMR   ________ ________ ________ ________ ________ 	TB status  ________ ________ ________ ________ ________
HIB   ________ ________ ________ ________ ________ 	Other      ________ ________ ________ ________ ________

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:________________________________

© American College of Emergency Physicians and American Academy of Pediatrics. 
Permission to reprint granted with acknowledgement. 

Doc. # 35-05-20/07/03/24