Referring Physician Details
Name:*

Hospital/Clinic:*

Email:*

Contact No:*

Country:*

Patient Details
Name:*

Age:*

Gender:*

Male Female

Nationality:*

Parent/Guardian Details
Name:*

Contact No:*

Email:*


Clinical Signs
Haematology Time
Biochemistry Time
HR: 
CRT: 
BP: 
Resp Rate: 
Spo2: 
Temp: 
AVPU: 
GCS: 
Glucose: 
Urine o/p: 
Hb: 
WCC: 
Plats: 
PT: 
PTT: 
Na: 
K: 
Urea: 
Creat: 
Ca: 
Known multi-resistant pathogen carrier


ETT
Ventilation
Blood GasART VENCAP
Size: 
Length: 
Position: 
C-spine: 
FiO2
PIP: 
PEEP: 
Rate: 
pIrI: 
PCO2
PO2
HCO3
BE: 
Lactate: 

Fluids
Drugs
IV Access: 
Type of Fluid: 
Amount given: 
Muscle Relaxant: 
Inotropes: 
Prostin: 

Advice:

Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai
United Arab
Emirates