EH Application Online Form

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Name of Child

Nickname

Date of Birth

Health Card Number

PARENT/LEGAL GUARDIAN INFORMATION

Name

Relationship

Address

Home Phone

Work Phone

Cell Phone

Email Address

Name

Relationship

Address

Home Phone

Work Phone

Cell Phone

EMERGENCY CONTACT OR ALTERNATE DECISION MAKER

Name

Relationship

Address

Home Phone

Work Phone

Cell Phone

MOST RESPONSIBLE PHYSICIAN OR PRIMARY CARE PROVIDER

Name

Specialty

Address

Telephone

Fax

PHARMACY

Name

Address

Telephone

Fax

COMMUNITY RESOURCES

CCAC Case Manager

Telephone Number

Social Worker

Telephone Number

Dietician

Telephone Number

SCHOOL

Name of School

Teacher's Name

Telephone Number

FAMILY INFORMATION

Who does your child live with? (including siblings and ages of siblings)

Please list any other individuals or family members who are involved in care

If you would like to allow visitors other than the immediate family, please fill out our visitor list on admission

MEDICAL INFORMATION

What is your child's medical diagnosis and medical condition?

Please provide pertinent history (previous surgeries, procedures, other illnesses)

Does your child have any allergies?

If so, please describe allergy triggers, reaction and treatment. Please indicate if this is a severe or life-threatening allergy.

Are your child's immunizations up to date?

Please provide a copy of your child's immunization record or provide information regarding any missing immunizations.

DOES YOUR CHILD HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS OR DEVICES? PLEASE SELECT ALL BOXES THAT APPLY. MORE INFORMATION WILL BE COLLECTED DURING INTAKE:

seizure disorder

behavioral care needs

central venous access device- including PICC line, implanted port (port-a-cath, power port), tunneled (Hickman) line, or other central line

peripheral intravenous therapy

tracheostomy

oxygen therapy

mechanical ventilation, including CPAP or BIPAP

G-tube, GJ-tube, or NG tube feeding

total parenteral nutrition (TPN)

ostomy

indwelling or intermittent urinary catheterization

wound care or specialized skin care

routine peritoneal or hemodialysis

Please describe any other specialized medical care or concerns:

Please include any sensory impairments such as hearing or visual impairments, and if any interventions are used.

What are your main goals of care for your child during their stay at Emily's house?

Pain Management

Does your child have a history of pain?

If so, please describe

What medications does your child use to treat pain?

What other therapies does your child use to treat pain?

Examples include heat/cold application, massage, guided imagery, distraction, etc.

Does your child use a pain scale to describe his/her pain?

If so, please indicate which scale, and how it is used

Medications- Please list current medications in chart below, or provide us with a copy of your child's prescriptions and medication times / routine (Press the "+" button to add another medication)

MEDICATION NAME AND CONCENTRATION

DOSE

ROUTE

TIME(S) GIVEN

REASON GIVEN

PLEASE TELL US A LITTLE BIT ABOUT YOUR CHILD, AND HIS/HER INTERESTS:

Favourite colour?

Favourite books?

Favourite activities/toys?

Favourite music?

What makes your child happy?

MOBILITY

Does your child move independently?

If not, please describe assistive devices used

Describe any special positioning required for your child, for seated and lying positions:

Does your child require daily range of movement exercises?

If so, please describe here or attach exercise instructions below

Attach Exercise Instructions

Max. file size: 3 GB.

TOILETING

Does your child have a toileting routine?

If so, please describe the usual routine

Does your child require diapers?

If so, please indicate type and size

How often does your child usually have a bowel movement?

Does your child have a routine for constipation?

If so, please describe routine

HYGIENE

Does your child usually have a:

tub bath

shower

sponge / bed bath

How frequently is your child bathed?

What time of day is your child bathed?

How often is your child's hair washed?

How often are your child's teeth brushed?

SLEEP

Does your child usually sleep in a:

bed

crib

Please describe your child's bed time and routine

Please describe nap time routines, if your child naps

What time does your child normally wake up? if you child wakes up at night, how do you settle him/ her?

DIETARY INFORMATION

Is your child fed orally?

If no, describe how your child is fed

If yes, what type of diet is required?

regular diet

soft diet

pureed foods

vegetarian/vegan- please describe restrictions below

kosher- please describe restrictions below

halal- please describe restrictions below

other- please describe restrictions below

Please select all that apply

Please list any dietary restrictions, including food allergies, dislikes, and additional information on special diet, if selected above

Please list some of your child's favourite foods

Please describe any feeding routines your child has at home, including feeding strategies, meal and snack times, etc.

Does your child require assistance with feeding?

If so, please describe