Fillable Printable First Aid Report Sample Form

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

TIMEPULSERESP.B/PSKINTEMP.AVPU

FIRST AID GIVEN AND SUPPLIES ISSUED

______________________________________________________________________________________

Form completed by: _____________________________