First Aid Forms

							                            FIRST AID REPORT FORM


Date:                                                            Time:

Name of victim:                                                  Name of rescuer:

Address:                                                         Address:


Phone:                                                           Phone:

Age:                             Sex:

Parent/Guardian:


PRIMARY SURVEY                          Time:

Check hazards                                                    Open airway

Consider mechanism of injury            Possible spinal? Y   N   Breathing          Y    N

LOC:       responsive   unresponsive                             Circulation:       Deadly bleeding        Y   N

Activate EMS?           Y   N                                    Treat for shock


SECONDARY SURVEY
VITAL SIGNS:

1 Time:__________                                                2 Time:__________

Level of Consciousness (LOC)                                     Level of Consciousness (LOC)

Conscious: Oriented to person, place & time?        Y   N        Conscious: Oriented to person, place & time?      Y   N
Unconscious:     Response to stimuli? Y N                        Unconscious:     Response to stimuli?      Y      N
             sound touch     pain                                             sound touch     pain

Breathing:                                                       Breathing:

    Rate:                                                            Rate:
    Rhythmn:       Regular Irregular                                 Rhythmn:       Regular Irregular
    Depth:         Normal Shallow Deep                               Depth:         Normal Shallow Deep
    Sounds:                                                          Sounds:

Pulse:                                                           Pulse:

    Rate:                                                            Rate:
    Rhythmn:       Regular Irregular                                 Rhythmn:   Regular Irregular
    Depth:         Normal Shallow Deep                               Depth: Normal Shallow Deep

Pupils:        Equal?        Y   N                               Pupils:        Equal?        Y   N
               React to light?   Y N                                            React to light?   Y N
    Size:      Right: small      normal     large                    Size:      Right: small      normal   large
               Left:    small    normal     large                               Left:    small    normal   large

Skin condition:                                                  Skin condition:
    Temperature:      cold     normal hot                            Temperature:      cold     normal hot
    Color: grey/blue       white   normal                            Color: grey/blue       white   normal
             pink     red                                                     pink     red
    Moisture:     dry wet                                            Moisture:     dry wet
HEAD TO TOE EXAMINATION

                                            Do a thorough head to toe examination.

                                            Check distal sensation & circulation for all
                                            limbs.

                                            Mark and number the location of all injuries
                                            on the drawings.

                                            Medic Alerts:      Y   N

                                            List Medic Alert conditions:




               Front                                                                       Back


HISTORY:
Medications?     Y     N    List:

Has this happened before?           Y   N    Describe:


Describe what happened:



TREATMENT:




WITNESSES:
Name:                                                                  Name:

Address:                                                               Address:


Phone:                                                                 Phone: