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HERO Kids Registry™

Health Emergency Ready Oregon

In an emergency, every moment counts

Primary Diagnosis / Condition(s)

Blood Type (if unknown leave blank)

Please select one value

Does the child or young adult have baseline vitals outside of the normal range for age?

Medical Equipment or Technology

(Examples: shunts, lines, implants, prostheses)

Medical equipment or technology name

Comments

Mobility Devices

(Examples: walker, wheelchair)

Mobility Device Name

Comments

Medication Allergy

(Examples: aspirin, latex)

Medication Allergy Name

Comments

Environmental or Food Allergy

(Example: bee stings, peanut butter)

Allergy Name

Comments

Current Medications/Prescriptions

Medication Name

Dose

Units

Please select one value

Dose Schedule

Please select one value

History of Alcohol Use?

History of Drug Use?

If transported, what is the preferred hospital?

Reason for choosing hospital

Make a selection by pressing the + button and check all that apply