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Get Checklist For Tonsillectomy For Children Form

PCP Checklist for Tonsillectomy in Children Patient Name Patient DOB Anthem Member PCP Name Accompanying Referral Referral Date PCP to complete send to ENT specialist 1. Has the patient had a pattern of recurrent of throat infections check as applicable 7 episodes in past year 5 episodes per year for 2 years Has at least one of the following been associated with every episode Temperature 38. 3 C 100. 94 F Cervical adenopathy Tonsillar exudates or erythema Positive test for Group A -hemolytic streptococcus GABHS Yes No OR 2. Does the patient have history of recurrent throat infections with any of these factors check all that apply Multiple antibiotic allergies/intolerances PFAPA periodic fever aphthous stomatitis pharyngitis and adenitis syndrome Peritonsillar abscess Parapharyngeal abscess Tonsillar hypertrophy a diagnosis of sleep-disordered breathing and a condition related to the sleep-disordered breathing e*g* growth retardation poor school performance enuresis and behavioral problems that is likely to improve after tonsillectomy. Has the patient had a pattern of recurrent of throat infections check as applicable 7 episodes in past year 5 episodes per year for 2 years Has at least one of the following been associated with every episode Temperature 38. 3 C 100. 94 F Cervical adenopathy Tonsillar exudates or erythema Positive test for Group A -hemolytic streptococcus GABHS Yes No OR 2. 3 C 100. 94 F Cervical adenopathy Tonsillar exudates or erythema Positive test for Group A -hemolytic streptococcus GABHS Yes No OR 2. Does the patient have history of recurrent throat infections with any of these factors check all that apply Multiple antibiotic allergies/intolerances PFAPA periodic fever aphthous stomatitis pharyngitis and adenitis syndrome Peritonsillar abscess Parapharyngeal abscess Tonsillar hypertrophy a diagnosis of sleep-disordered breathing and a condition related to the sleep-disordered breathing e*g* growth retardation poor school performance enuresis and behavioral problems that is likely to improve after tonsillectomy. Has the patient had a pattern of recurrent of throat infections check as applicable 7 episodes in past year 5 episodes per year for 2 years Has at least one of the following been associated with every episode Temperature 38. 3 C 100. 94 F Cervical adenopathy Tonsillar exudates or erythema Positive test for Group A -hemolytic streptococcus GABHS Yes No OR 2. Does the patient have history of recurrent throat infections with any of these factors check all that apply Multiple antibiotic allergies/intolerances PFAPA periodic fever aphthous stomatitis pharyngitis and adenitis syndrome Peritonsillar abscess Parapharyngeal abscess Tonsillar hypertrophy a diagnosis of sleep-disordered breathing and a condition related to the sleep-disordered breathing e*g* growth retardation poor school performance enuresis and behavioral problems that is likely to improve after tonsillectomy..

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