Addressograph
Alberta RSV Prevention Program
Risk Assessment Form 2014-2015
Referring Site:
Child’s Full Name:
Surname
Birth Gestational Age:
Given
Date of Birth:
Current
Community Pediatrician/Family Physician:
Name
Location
Primary Language:
Mother:
Father:
Name:
Cell:
Name:
Cell:
Middle Initial
Weight in grams:
Birth
Place of Residence:
Home Telephone:
Telephone Number
PLEASE CHECK ALL APPLICABLE QUALIFIERS BELOW:
YES
1. Premature: ≤32 6/7 weeks GA born after May 31, 2014 i.e. <6 months of age as at December 1, 2014
2. Premature: 33 0/7 – 35 6/7 weeks GA and born after October 31, 2014
Please check all applicable risk factors below
Yes
Is birth month in November, December, January or
February?
No
Yes
No
Are there more than 5 individuals in the home
counting the child?
Is there more than one smoker in the household?
Small (<10th percentile) for gestational age?
Does family live >2 hours from a hospital that
provides bronchiolitis treatment?
Is gender male?
Is child or sibling attending daycare ≥ 3 “half”
days/week?
3.
Premature: 33 0/7 – 35 6/7 weeks GA otherwise healthy and a twin/triplet of a patient who qualifies for
RSV immunoprophylaxis
4. Premature: ≤35 6/7 weeks GA and < 2 years of age as at December 1, 2014 with chronic lung disease
as evidenced by: Check all applicable factors
home O2 after May 31, 2014
on long term prophylaxis or recent exacerbation needing systemic steroids Details:
5. Severe hemodynamically significant congenital heart disease: age < 2 years of age as at December 1, 2014
Provide specific diagnosis and/or cardiac meds:
Approved by Cardiologist (Name):
6. Tracheostomy: age < 2 years of age as at December 1, 2014
7. Cystic Fibrosis: age < 2 years of age as at December 1, 2014
8. Trisomy 21: age < 1 year of age as at December 1, 2014
9. Other Categories:
age < 2 years of age as at December 1, 2014 i.e. home O2, meconium aspiration with long term O2
supplements, congenital diaphragmatic hernia, Pierre Robin sequence, stem cell transplant, diagnosed with significant congenital
immunodeficiency, congenital anomaly of lung or airway, GERD with long term O 2 supplements, Exception: SMA Type 1 weighing < 15 kg
State Diagnosis:
10. Others not listed above, please include supporting documentation
State Diagnosis:
Completed by:
Name
*Requires Program Approval
Telephone Number:
Designation
Date:
dd-mmm-yyyy
Fax completed form to the Alberta RSV Prevention Program in your respective part of the province
For more information go to www.albertahealthservices.ca/rsvprogram.asp
Northern Alberta RSV Prevention Program
Southern Alberta RSV Prevention Program
Edmonton & Northern Alberta (includes Red Deer)
Calgary and Southern Alberta
Fax: (780) 735-6919
Phone: (780) 735-4205
Fax: (403) 955-7779 Phone: (403) 955-2283
Draft
Original to remain on chart
Revised May 2014