PARTICIPANT APPLICATION FORM
Print, and mail completed form to:
New Jersey WAVE
c/o Voorhees Pediatric Facility
Attention: Tricia Cunnungham
1304 Laurel Oak Road
Voorhees, NJ 08034-4392
Child's Full Name:__________________________________________________________
Address_________________________________________________________
Telephone # ____________________________________________________
Parent/Guardian:___________________________________________________
Date of Birth: ______________________________________________________
Allergies:__________________________________________________________
_________________________________________________________________
Diagnosis:_________________________________________________________
Respiratory Status
Ventilator Name: Mode: ______________________________________________________
Tidal volume_________IPAP:________ Rate: ________
PEEP/CPAP: ________ FIO2: _______
Pressure limit: High/low press. Alarm: ______________________________________________
Weans to: (mode)____________________________________________________________
Wean for: (how long)_____________________________________________________________
Tracheostomy Brand: Size: Ped/Adult: __________________________________________
Speech valve: _________________________________________________
Aerosol/MDI medication/dose:
Dose:_______________________________
Frequency: ___________________________
Airway Clearance (CPT,in-exsufflator, etc...): ___________________________________________
___________________________________________
Medications
Medication: _____________________Dose:_____________Frequency:____________
Medication:______________________Dose:_____________Frequency:____________
Medication:______________________Dose:_____________Frequency:____________
Medication:______________________Dose:_____________Frequency:____________
Medication:______________________Dose:_____________Frequency:____________
Nutrition
Diet type: Regular Food: Pureed Food: Baby Food: Formula
Thin Liquids Thick Liquids:_____________________________________________________________
Special Feeding Needs:Equipment: _____________________________________________________
Techniques:__________________________________________________________
Positioning:___________________________________________________________
Tube Feeds: NG, GT:_______________________________
Water: Amount Times
_____________________________________________________________________
Elimination
Voiding Pattern: Voluntary Diapers:______________________________________________
CIC: Frequency: _____________________________________________________
CIC Catheter Type: Size:__________________________________________________________
Bowel Pattern: Voluntary Diapers:______________________________________________
Bowel Program: ____________________________________________________________
Mobility
Ambulatory: With Assistive DevicesType:______________________________________________________
Without Assistive Devices:__________________________________________________________
Use of Orthosis( MAFOs,KAFOS,TLSOs ect.): _________________________________________________
Hospital Bed:Regular Bed: Crib: Special Mattress: ______________________________________________
Turns Self:_________________
Turns every hours:_________
Positioning Equipment Needs:______________________________________________________
Weight: lbs.:__________________
Activities of Daily Living Participation
Participates in self-care activitites:
Independent:______________
With assistance:___________
Total assistance:___________
Describe self-care activities independently completed: _____________________________________
___________________________________________________________________
ADL Adaptive Equipment Needs:______________________________________________________
___________________________________________________________________
Home Equipment (Brand and Model)
Apnea Monitor: Pulse Oximeter:________________________________
Portable Suction: Feeding Pump: _______________________________
Air Compressor: Humidifier: ____________________________________
Home OxygenLiquid: __________________________________________
Concentrator: _______________________________________________
Portable OxygenLiquid:________________________________________
Cylinders:___________________________________________________
Other Equipment:_____________________________________________
Community Care Providers
Homecare Case Manager: Phone: ______________________________
Homecare Agency: Phone: ___________________________________
Medical Equipment : Phone: __________________________________
Physician: Phone: __________________________________________
Activities / Education
Education Level: Grade: ______________________________________
Means of Communication: ______________________________________
Activities of Interest:____________________________________________
Level of Participation:
Independent:_________________
With assistance:______________
Total Assistance:______________
Adaptive Recreational Equipment Needs: _____________________________________________
___________________________________________________
Describe Child's Social Skills: _____________________________________________________
___________________________________________________________
___________________________________________________________