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: _____________________________

Fillable Printable First Aid Report Sample Form