Sample Workplace First Aid Incident Form

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Sample Workplace First Aid Incident Form Printable pdf

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Sample Workplace First Aid Incident Form

Name:

Date:

Time:

Sex:

M

F

Address:

Phone Number:

Location:

Date of Birth:

YEAR

MONTH

DAY

Chief Complaint:

Mechanism of Injury/History of Event:

INTERVIEW

S

O

A

P

M

Q

P

R

L

S

E

T

ALLERGIES

None

Environmental (e.g., food, pollen)

Medications (ASA, Penicillin, Sulpha, Codeine)

Not Determined

MEDICATIONS

®

Erectile Dysfunction

Ventolin

/

Over-the-Counter

Insulin

Birth Control

Drugs

Salbutamol

None

Prescribed (ASA, Nitroglycerin,

®

®

Lasix

/Furosemide

Flovent

Oral Sugar Pills

Not Determined

Erectile Dysfunction Drugs, Insulin)

RELEVANT MEDICAL HISTORY

Cardiac

Respiratory

Stroke/TIA

Seizures

Falls

Previously Healthy

Diabetes

Psychiatric

Cancer

High Blood Pressure

Not Determined

Other (specify)

Sample Workplace First Aid Incident Form

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