Patient Medical History Form

Pediatric Special Needs EMERGENCY Information Form

Kirby Ambulance
Patient Name*

First NameLast Name
Nickname
Patient Gender*
Patient Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Patient Height (cm's)
Patient Weight (kg's)
Emergency Contact Information *
Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)

ADHDAnemiaAnxiety disorderAsthmaAutism Spectrum Disorder (ASD)Behavioral outbursts/AggressionCancerCerebral palsyCochlear implantDevelopmental delayDiabetesDigestive ProblemsEmotional DisorderFailure to thriveFainting SpellsFeeding tube (G-tube/J-tube/NG)Genetic disorder (specify)Hearing impairment/DeafnessHeart surgery (specify)History of febrile seizersHistory of frequent pneumoniaImmunocompromisedIntellectual disabilityLimited mobilityMuscular dystrophyNeurological DisordersOstomyOxygen dependentPTSDRequires behavioral plan/de-escalation strategiesScoliosisSeizure Disorder/EpilepsySelf-injurious behaviorSensory processing disorderSickle cell diseaseSpecialized dietSpina bifidaStroke/brain injurySwallowing difficulty/Aspiration riskTracheostomyVentilator dependent (home vent/biPAP/CPAPVision impairment/BlindnessWheelchair dependentOther
Other illnesses:
Please list your Current Medications
Method of Communication
VerbalNon-VerbalAmerican Sign Language (ASL)Picture BoardWritten WordsOther
Describe any unique or special behaviors or characteristic, including Sensory/Medical Needs
Describe best approach for responders to use for this individual *
Can this information be shared with dispatch? This allows them to give important information to first responders during an emergency.*

YesNo
Should be Empty:

Pediatric Special Needs EMERGENCY Information Form

Patient Medical History

Method of Communication