DESERT WILLOW TREATMENT CENTER



DIVISION OF CHILD AND FAMILY SERVICES

|NAME: | |

|ADMISSION DATE/TIME: | A.M. P.M. |

|DIAGNOSIS: | |

|DOB: | |

|ALLERGIES: | |

ADMISSION:

Sedona Residential Sunrise Residential SATP Residential COD Residential

LABS:

| Comprehensive Metabolic Panel | | Urine Drug Screen |

|Lipid Panel | |HIV-1 AB Screen w/ reflex |

|CBC w Diff w Platelet Ct | |PPD |

|Pregnancy, HCG Total Quant | |TSH |

|Urinalysis | |Chlamydia Trachomitis DNA Amplified |

Other

PRECAUTIONS:

Routine q 15-min checks 1:1 SP I SP II

Seizures AWOL Building Restriction

Other

Diet: Regular

Therapy: Individual, Family: THERAPIST:

VS: Admission and q week

WT lbs on admission and q week

HT ' " on admission and q monthly

Physical Exam

Lice Check, Call M.D. if (

Other

MEDICATIONS:

Tylenol 650 mg T q 4 hrs PRN Pain or Fever – Not To Exceed 2 doses in 24º OR

Ibuprofen 400 mg T q 4 hrs PRN Menstrual Cramps or Pain – Not To Exceed 2 doses in 24º

Maalox 30 ml po q 4 hrs PRN Upset Stomach – Not To Exceed 2 doses in 24º

MOM 30 ml q bedtime PRN Constipation

JUSTIFICATION FOR 2 OR MORE ANTIPSYCHOTIC MEDICATIONS PRESCRIBED:

A.M. P.M.

Date Time

M.D. M.D.

Physician Print Name Physician Signature

Witness Signature Date Parent / Legal Custodian Signature Date

VO TO RB/V

Patient Name Patient SS #

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Desert Willow Treatment Center

ADMISSION ORDERS

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