Physician Prescription Pad

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(Your Pediatric Office Here)
Name:
(Your Pediatric Office Here)
Date:
When you have tried everything else and the baby
still cries:
Name:
Date:
When you have tried everything else and the baby
still cries:
Try to establish a regular routine
Try to establish a regular routine
Hold Calmly
Hold Calmly
Gently Rock
Gently Rock
Recognize hunger cries
Recognize hunger cries
Swaddle
Swaddle
Get help if you feel exhausted or overwhelmed
Get help if you feel exhausted or overwhelmed
If alone, set the timer for 5 to10 minutes place the
infant in a crib or safe place, leave the room to “destress” and then try again
If alone, set the timer for 5 to10 minutes place the
infant in a crib or safe place, leave the room to “destress” and then try again
____________________________
Staff Signature
____________________________
Staff Signature
(Your Pediatric Office Here)
Lockman & Lubell Pediatric Associates
270 Commerce Drive, Suite 250
Fort Washington, PA 19034
215-653-0600
Name:
Date:
When you have tried everything else and the baby
still cries:
(Your Pediatric Office Here)
270 Commerce Drive, Suite 250
Fort Washington, PA 19034
15-653-0600
Name:
Date:
When you have tried everything else and the baby
still cries:
Try to establish a regular routine
Try to establish a regular routine
Hold Calmly
Hold Calmly
Gently Rock
Gently Rock
Recognize hunger cries
Recognize hunger cries
Swaddle
Swaddle
Get help if you feel exhausted or overwhelmed
Get help if you feel exhausted or overwhelmed
If alone, set the timer for 5 to10 minutes place the
infant in a crib or safe place, leave the room to “destress” and then try again
If alone, set the timer for 5 to10 minutes place the
infant in a crib or safe place, leave the room to “destress” and then try again
____________________________
Staff Signature
____________________________
Staff Signature
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