Triage Form

This tool is designed for children under age 12, whose parents feel they need to be seen by a doctor on the same day or next day. For emergencies or concerns regarding a very unwell child eg. non-blanching rash, difficulty breathing, reduced consciousness, do NOT proceed. Instead, please PHONE or attend the nearest Emergency Department.

Personal Details

Child's Name(Required)

Firstname Surname

Date of Birth(Required)

Parent's Email Address(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)

Off Form(Required)

Runny Nose(Required)

Off Food(Required)

Sore Throat(Required)

Sore Ear(s)(Required)

Absent 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

Triage Form

Triage Form

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