Get Severe Rsv Disease Risk Assessment - Rainbow Pediatrics - Rainbowpeds

Filling out the Severe RSV Disease Risk Assessment is an important step in evaluating the risk of severe respiratory syncytial virus (RSV) disease in your child. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form seamlessly.

1. Click ‘Get Form’ button to obtain the document and access it in your preferred online tool for editing.
2. Begin by entering your child's name in the designated field. Next, input the date on which you are completing the form.
3. Provide your child's date of birth. Ensure that this entry is accurate as it is critical for assessing risk factors.
4. Fill in the gestational age (GA) in weeks. This information helps identify any prematurity-related risks.
5. Enter your child's birth weight in pounds. Accurate weight is relevant for evaluating health risks.
6. Respond to the initial question by checking 'Yes' or 'No' if your child has chronic lung disease of prematurity, significant congenital heart disease, or any serious condition affecting pulmonary or immune function. Mark the appropriate box.
7. Indicate whether your child was born prematurely (less than 35 weeks GA) by selecting 'Yes' or 'No.'
8. If applicable, specify your child's gestational age at birth in weeks.
9. In the next section, check all applicable risk factors for your child, such as having siblings, attending daycare, living in crowded conditions, exposure to smoke, low birth weight, being a multiple birth, family history of respiratory issues, airway abnormalities, or severe neuromuscular disease.
10. At the end of the form, ensure that you sign it with your name as the parent or guardian. Also, include the date of your signature.

Complete the Severe RSV Disease Risk Assessment online to ensure your child's health and safety.