Are you evaluating a pediatric patient?

Age of the patient

Body temperature

Systolic blood pressure

mm Hg

Diastolic blood pressure

mm Hg

Was the patient referred in from a doctor's office or transferred from another ED?

Does the patient have?

• have a sprain, strain, laceration, simple fracture or other minor injury?

• have abdominal pain as chief complaint?

• have a depressed mental status?

• HIV, organ transplant or other immunodeficiency state?

• a malignancy?

• sickle cell anemia?

• a tracheostomy?

• a long term venous catheter or vascular access device?

• a dialysis catheter or shunt?

• a ventricular drainage catheter?

• a feeding tube?

• a home apnea monitor?

• home oxygen therapy?

• a need for supplemental oxygen?

• a need for an asthma medication other than a bronchodilator?

Serum bicarbonate

Serum potassium

Serum BUN

White blood cell count


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