Triage Form

Personal Details

Child's First Name(s)(Required)

Child's Surname(s)(Required)

Date of Birth(Required)

Parent's Email(Required)

Symptoms

0 - none/not applicable 1 - today only 2 - one or two days duration 3 - three or more days duration

Fever(Required)

Cough(Required)

Runny Nose(Required)

Off Form(Required)

Off Food(Required)

Sore Throat(Required)

Sore Ear(s)(Required)

Excluded from Childcare/School(Required)

Treatment

Fever coming down with calpol/neurofen(Required)

Already seen by a doctor in this illness episode and not getting better(Required)

Additional Information

Any additional info? Eg. Rash, vomiting, diarrhoea, headache

If a rash is present, please do the tumbler glass test.(Required)

If the rash does not fade/disappear on pressure - do NOT email a photo. Instead, phone us without delay. This may be a sign of a rare but serious bacterial infection that requires urgent medical attention.

I understand

(091) 530054

info@GalwayBayMedicalCentre.ie

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