FIRST AID EVALUATION

Patient Chart

VICTIMS CONTACT INFO

INITIAL ASSESSMENT
Level of Consciousness

Name

Date of Incident

Time of Incident

AM

Phone / Frequency / Call Sign

PM

Pulse

Breaths

Temp

Adult Normals:
Pulse 60-100/m
Breaths 12-15/m
Temp 98.6 F
Cap refill < 2s
Pupils: equal & reactive

Emergency Point of Contact (POC)

POC Phone / Frequency / Call Sign

FIRST AID APPLIED

Examine: Head, Neck, Chest, Abdomen, Pelvis, Extremities, Back, Skin

Note: Identify all deformities and wounds on graphics above

HISTORY
Signs & Symptoms______________________________________________________
_______________________________________________________________________
Allergies / Med-Alerts____________________________________________________
_______________________________________________________________________
Medications_____________________________________________________________

Name of Evaluator

_______________________________________________________________________
Pertinent Past History____________________________________________________
_______________________________________________________________________
Last Food or Drink_______________________________________________________
_______________________________________________________________________
Events Leading to Accident_______________________________________________

Pressure Dressing Applied

Yes

No

Tourniquet Applied

Yes
Date Started

Time Applied

Time Applied

No
Time Started

_______________________________________________________________________

AM
PM

2012 PrepperLink. All Rights Reserved. This PDF may be distributed freely, but not altered in any way.

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This document is a modified version of the Wilderness First Aid Evaluation Form (www.riteintherain.com). Join PrepperLink.com for FREE to get downloads, meet other preppers, and start your own group.

Alert
Responds to Pain
Responds to Verbal Unresponsive

FIRST AID EVALUATION

Patient Chart

VITAL SIGN RECORD

Date

Time

LOC
(AVPU) Rate

Every 15 minutes for 1st hour or if changing. Every hour if stable.

Pulse
Character

Pulse below injury

Rate

Character

Breaths
Rate

Character

Pupils

Skin

Other

AM
PM
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PM
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PM

This document is a modified version of the Wilderness First Aid Evaluation Form (www.riteintherain.com). Join PrepperLink.com for FREE to get downloads, meet other preppers, and start your own group.

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2012 PrepperLink. All Rights Reserved. This PDF may be distributed freely, but not altered in any way.

DOC 02-001-12

PAGE 2 of 2