First Aid Report Sample Form

First Aid Report Form
INITIAL ASSESSMENT
Level of Consciousness (Circle One): A V P U
Respirations: __________________________________
Pulse: ________________________________________
SAMPLE HISTORY
Signs and Symptoms: ___________________________
_____________________________________________
_____________________________________________
Allergies: _____________________________________
_____________________________________________
_____________________________________________
Medications: __________________________________
_____________________________________________
_____________________________________________
Past History: __________________________________
_____________________________________________
_____________________________________________
Last Oral Intake: _______________________________ Date: ___/___/___
_____________________________________________ Time: _________ AM or PM (Circle One)
_____________________________________________ Victim’s Name: ________________________
Events Leading to Accident: _____________________ Male or Female (Circle One)
_____________________________________________ Age: ____
_____________________________________________ Phone Number: ______-______-________
PHYSICAL EXAM (DOTS) City: _________________________________
Head: ________________________________________ State: ________________________________
Neck: ________________________________________ Zip Code: ________
Chest: _______________________________________ ADDITIONAL NOTES
Abdomen: ____________________________________ _____________________________________
Pelvis: _______________________________________ _____________________________________
Extremities: ___________________________________ _____________________________________
Back: ________________________________ ______________________________
VITAL SIGNS
TIME PULSE RESP. B/P SKIN TEMP. AVPU
/
/
/
/
/
FIRST AID GIVEN AND SUPPLIES ISSUED
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Form completed by: _____________________________
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First Aid Report Sample Form PDF

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