RSV Prophylaxis Screening

Baby’s Name

Date of Birth

Parent's Name

Home Phone

Birth Hospital

Was your baby born early?

Yes No

If yes, How many weeks early?

Did your baby have breathing difficulties at birth?

Yes No

If yes, Please Explain

Please check any of the following that apply

Daycare (First year of Life)

Siblings @ home

Twins/Multiple births

Tobacco use in home

Group play with other children >4hrs/wk

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Physician signature

Date

TO BE FILLED OUT BY THE PHYSICIAN

Synagis Eligibility

PREMATURITY - < GA 28 weeks, 6 days AND < 12 months at start of the RSV season

CHRONIC LUNG DISEASE (CLD)- CLD of prematurity defined as GA < 31 weeks, 6 days, AND requirement for 21% oxygen for at least 28 days after birth.

< 12 months of age with CLD

12 - 24 months of age with CLD AND continues to require medical support during the 6 months Period before second RSV season AND Supplemental O2, Diuretic therapy, Bronchodilators, Chronic Corticosteroids.

CONGENITAL HEART DISEASE (CHD) - <12 months of age at start of RSV season With hemodynamically significant CHD such as:

Acyanotic heart disease and receiving medications

Moderate to severe pulmonary hypertension

< 24 months of age undergoing cardiac surgery during the RSV season

Cyanotic Heart Disease

AIRWAY/NEUROMUSCULAR CONDITIONS - < 12 months of age at start of season AND due to: Significant abnormality of the airway, Neuromuscular condition, Cystic Fibrosis.

NO, this baby does not qualify for RSV prophylaxis

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