Are you evaluating a sick child who is dehydrated?

Birthday of the child(enter MM/DD/YYYY)

Date of evaluation (enter MM/DD/YYYY)

Was the child born premature?

Are the parents or caregivers able to provide adequate care at home?

Is there a problem that would prevent the child's return if significant deterioration occurs?

Has there been a reasonable attempt to give oral rehydration solution?

Has the child had adequate intake of oral rehydration solutions?

Does the child show an unusual irritability or drowsiness?

Has the child shown a progressive clinical deterioration?

Are you uncertain about the diagnosis?

Does the child have one or more significant comorbid conditions?

Could the child be septic or have a significant infection?

Is the child severely dehydratied?


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