| Substance History |
- Substance(s) ingested
- Amount ingested
- Dosage
- Number of pills
- Amount of liquid
- Route(s) of exposure
- Aspiration
- Ingestion
- Inhalation
- Time of exposure
- Risk of Poly-substance Exposure
- General inventory of prescription and over-the-counter medications in the home
- Location and accessibility of other chemicals, toxins and substances in the home
|
| Symptoms |
- Types and timing of symptoms prior to arrival
- Progression or resolution of observed symptoms
|
| Attempted Therapies |
- Time and frequency of therapies received prior to arrival
- Response to therapies received
|
| Poison Control Center |
Poison Control Center recommendations
|
| Social/Behavioral History |
- Identify potential social concerns
- History inconsistent with developmental/chronological age
- Lack of child supervision
- Substance use disorder and/or treatment in child’s care environment
- Caregiver concerns about child’s safety
- Prior ingestions
- Other minors in the home or care environment potentially affected
- Behavioral health
- Suicidal ideation or intent
- History of substance use disorder
- History of mental health disorder
- Behavioral health screen (BHS)
|
| Past Medical History |
- Hepatic or renal failure
- Metabolic disorder that may impact drug pharmacokinetics
|