Loretta's Little Miracles: Daily Health Admittance Patient + Caregiver(s) survey

DO NOT USE THIS SURVEY as of 8/26/23

NEW:
Patient Daily Admission Survey Link:

https://forms.office.com/r/PVXV94vMCC

Question Title

* 1. CLIENT / CHILD'S NAME

First Name:

Last Initial:

Question Title

* 2. Approximate Time Child to arrive to Loretta's Little Miracles

Time

AM/PM

Question Title

* 3. NAME of the CAREGIVER who is DROPPING OFF the CHILD & what time child will be dropped off.
(not necessarily the person completing this form)

First Name:

Last Name:

Question Title

* 4. CAREGIVER who is DROPPING OFF relation to the child:

Parent - living in the SAME HOME with the child

Parent - living OUTSIDE the HOME of the child

Relative - living in the SAME HOME with the child

Relative -living OUTSIDE the HOME of the child

Caregiver Completed - TRANSPORT SERVICE brought child

Friend/paid employee

Other (please specify)

Question Title

* 5. Name the Caregiver who will be picking up the child and what time pick-up will be:

(If designated person is not already on approved list by parent/legal guardian & LLM the child's parent/legal caregiver MUST EMAIL AUTHORIZATION. Please provide individual's legal name. Upon arrival the designated pick-up person must present Legal ID/Drivers License for child to be released)

First Name:

Last Name:

Pick-Up Time:

Question Title

* 6. Has the CHILD, YOU or ANYONE IN YOUR HOUSEHOLD been EXPOSED to someone who has TESTED POSITIVE FOR COVID-19 in the past 14 days?

YES or UNSURE - Provide name and relation of this person to the child. DATE of EXPOSURE. Date the CHILD or ANYONE in your household came in contact with this person. Note any other details you think we should know:

Question Title

* 7. Has the CHILD experienced any of the following symptoms in the past 72hrs (3days): (Check all that apply)

NO SYMPTOMS - The CHILD and/or ANYONE in the child's or MY HOUSEHOLD have any of the below symptoms

Fever or Chills

Coughing / Sneezing (not allergy related)

Difficulty Breathing or Shortness of Breath

Fatigue

Muscle or Body Aches

Headache

Loss of Taste or Smell

Sore Throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

Question Title

* 8. I have read and understand the Loretta's Little Miracles Patient Sick Policy.

At this time the child's health status is in compliance with this policy.

AGREE

Please provide me with another copy of the Patient Sick Policy

Question Title

* 9. Drop-Off: Items or concerns you need to share with LLM Nurse to provide the best care of the child.
(feel free to call if needed (559) 226-1225)

N/A

Notes for Nurse:

Question Title

* 10. Drop-Off: When is your child's next feeding after Drop-Off?

Date / Time

Time

AM/PM

Question Title

* 11. Drop-Off: When is next dose of MEDICATION needed after drop-off
(DO NOT COMPLETE if not applicable)

Date / Time

Time

AM/PM

Question Title

* 12. I have evaluated my child and confirm that he/she is free of communicable disease/infection or has a known health hazard of lice, bed bug/bites and blisters that are easily transmitted from person to person during direct contact to my knowledge. I am aware upon arrival my child will be screened by LLM Staff.

Yes

Question Title

* 13. I understand that Loretta's Little Miracles cares for high-risk pediatric patients who are at greater risk for all infections - including COVID-19.

I hereby confirm I have answered all questions above TODAY to my best knowledge as a health precaution for the child under my care and to protect the other children who are being cared for in this licensed Pediatric Day Health Care facility.

I need to talk to an LLM Employee before confirming.

Question Title

* 1. CLIENT / CHILD'S NAME

Question Title

* 2. Approximate Time Child to arrive to Loretta's Little Miracles

Question Title

* 3. NAME of the CAREGIVER who is DROPPING OFF the CHILD & what time child will be dropped off.(not necessarily the person completing this form)

Question Title

* 4. CAREGIVER who is DROPPING OFF relation to the child:

Question Title

Question Title

* 6. Has the CHILD, YOU or ANYONE IN YOUR HOUSEHOLD been EXPOSED to someone who has TESTED POSITIVE FOR COVID-19 in the past 14 days?

Question Title

* 7. Has the CHILD experienced any of the following symptoms in the past 72hrs (3days): (Check all that apply)

Question Title

* 8. I have read and understand the Loretta's Little Miracles Patient Sick Policy. At this time the child's health status is in compliance with this policy.

Question Title

* 9. Drop-Off: Items or concerns you need to share with LLM Nurse to provide the best care of the child. (feel free to call if needed (559) 226-1225)

Question Title

* 10. Drop-Off: When is your child's next feeding after Drop-Off?

Question Title

* 11. Drop-Off: When is next dose of MEDICATION needed after drop-off(DO NOT COMPLETE if not applicable)

Question Title

Question Title

* 13. I understand that Loretta's Little Miracles cares for high-risk pediatric patients who are at greater risk for all infections - including COVID-19.

* 3. NAME of the CAREGIVER who is DROPPING OFF the CHILD & what time child will be dropped off.
(not necessarily the person completing this form)

* 8. I have read and understand the Loretta's Little Miracles Patient Sick Policy.

At this time the child's health status is in compliance with this policy.

* 9. Drop-Off: Items or concerns you need to share with LLM Nurse to provide the best care of the child.
(feel free to call if needed (559) 226-1225)

* 11. Drop-Off: When is next dose of MEDICATION needed after drop-off
(DO NOT COMPLETE if not applicable)