INFORMATION FOR SICK VISIT OR ILLNESS RELATED
PHONE CALL TO PCP
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Child's Name: |
Child's Age: |
Weight (last time it was taken)
Temperature (before giving any medication)
What signs are there that the child is sick?
When did the symptoms begin? Are the symptoms better
or worse?
What is the child's activity level and appetite?
What have you already done for the child?
Does the child have a chronic health problem? If yes
describe.
Is the child on any ongoing medications? If yes; name,
dose, when given.
Does the child have any drug allergies?
Is anyone else in the home ill? If yes, with what?
Pharmacy name and telephone number.
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