First Aid Incident Report - Form 140-C
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1
2FIRST AID INCIDENT REPORT
FORM 140-C
_________________________________________________________________________________
FIRST AID INCIDENT REPORT
DATE: ________________TIME: __________
Ambulance Requested:
Y N
CASUALTIES NAME: _____________________________
OVER 18? Y N
MEDICAL ALERT BRACELET? Y N
DETAILS: ______________________
EMERGENCY CONTACT: _____________________ PHONE #: ______________
NATURE OF INCIDENT OR INJURY:
CASUALTIES HISTORY:
WHAT HAPPENED?
HOW DO YOU FEEL?
DO YOU FEEL PAIN?
WHERE?
WHAT DOES IT FEEL LIKE?
DO YOU HAVE ALLERGIES?
ARE YOU ON MEDICATION?
DO YOU HAVE A MEDICAL CONDITION?
HAS THIS HAPPENED BEFORE?
NOTE:
BREATHING
PULSE
RESPONSIVENESS
PUPILS
ODOUR
LONG TERM HISTORY:
HAVE YOU EATEN TODAY?
WHAT DID YOU EAT LAST NIGHT?
HAVE YOU SLEPT?
HOW DID YOU FEEL EARLIER?
WHAT WERE THE SYMPTOMS?
HOW DID YOU TREAT YOURSELF?
PHYSICAL ACTIVITY TODAY?
EMOTIONAL STATE (STRESS)?
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