The Canadian Pandemic Influenza Plan for the Health Sector

) Children ≤ 18 years:
Identification
Health Care Number:
Name: ____________________________________________________________________________
Surname/Family Name
First Name
Age _____ (yrs)
DATE OF CONSULATION ____/____/______
DD MM YYYY
DOB ____/____/____
DD MM YYYY
Risk Assessment for Complications of Influenza
Does this patient fall into a “high risk group” for complications of influenza Y/N
Child with
High-Risk Groups
Chronic cardiac disease
Chronic pulmonary disease - asthma
Chronic pulmonary disease - other than asthma
Chronic renal disease
Diabetes mellitus
Child with cyanotic congenital heart disease
Receiving immunosuppressive therapy, AIDS patients
Neoplastic disease
Hepatic disease
Resident of long-term care facility
< 2 years old
Tick all relevant
56 The Canadian Pandemic Influenza Plan for the Health Sector