First Aid Report Form

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FIRST AID REPORT FORM

LOCATION:

TIME:

DATE:

TITLE:

D.O.B.:

SEX:

CASUALTY SURNAME:

GIVEN NAMES:

M / F

ADDRESS:

P/CODE:

PATIENT ASSESSMENT & OBSERVATIONS

LEVEL OF CONSCIOUSNESS

KEY

TIME

FULLY

CONFUSED

UNCONS.

A – ABRASIONS

B – BURN

CONSC.

DROWSY

C – CONTUSION

D – DISCOLOURATION

F – FRACTURE

H – HAEMORRHAGE

L – LACERATION

P – PAIN

R – RIGIDITY

S – SWELLING

VITAL SIGNS

T - TENDERNESS

TIME

PULSE

RESPS.

PUPILS

L

R

CHIEF COMPLAINT / SYMPTOMS / SIGNS

FIRST AID GIVEN



OXYGEN GIVEN



DEFIBRILLATION GIVEN

GENERAL OBSERVATIONS

REFERRAL FOR CARE

 HOSPITAL (BY AMBULANCE)

 HOSPITAL (BY CAR)

 OWN DOCTOR



CASUALTY REFUSED / DECLINED TO

RECEIVE ANY FIRST AID WHEN

OFFERED

ATTENDING FIRST AIDER’S NAME & SIGNATURE

NAME:

SIGNATURE:

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