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 UNK Service □ CIVLIAN

REPORT  HEAT
Patient
Nation
Name/Rank: _____________________________
□ USA □ CONTRACTOR  COLD
SSN:
□ US
_________________________________________
Date of Birth:
□ Host
□ USMC □ EPW
MEDEVAC PATIENT REPORT
___________________________________
Nation
□ USAF □ OTHER___________


BITE / STING
OTHER
( )Male
□ Enemy ( )Female
□ USN _ __________________
□ Coalition
MTF DESTINATION: UNIT: DATE/TIME:
- -

CALL TIME DISPATCH ARRIVE SCENE DEPART SCENE DESTINATION IN SERVICE

Wounded by:
□ US/Coalition
□ Enemy
□ Civilian
□ Accident
□ Other_______________________________
Mechanism of Injury:  STAB  BURN  HEAT
 GSW COLD
 BLAST  CRUSH 
 BLUNT TRAUMA  BITE / STING
 VEHICLE ACCIDENT  FALL
 SINGLE FRAGMENT  OTHER ______
 CARDIAC  MEDICAL
 MULTI FRAGMENT ________________________
Not Worn

Worn

Struck

Penetrated

Protection: GLASGOW COMA SCALE Procedures


EyeOpen Verbal Motor CPR
1 Spont A&O Follow CMD BVM
2 Speech Confused Localizes ET/ Combitube
3 Pain Nonsense Withdrawl
4 None Unintel Decorticate RSI
5 None Decerebrate Crichothyroidotomy
HELMET 6 None Chest
FLAK VEST TIME Decompression
Intraosseous
CERAMIC PLATE TEMP
LR/NS/HTS
EYE PROTECTION PULS I.V. ml
E
RESP Tourniquet Time on
Time off
BP
Hemostatic Dressing
SpO2
GCS Oxygen LPM

REPORT
MEDICATIONS(NAME,DOSE,TIME)________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___REPORT__________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
AM Amputation BL Bleeding D Deformity ___________________________________________________________
AV Avulsion B Burn F Foreign Body ___________________________________________________________
L Laceration P Puncture FX Fracture ___________________________________________________________
S Stab Wound GSW Gunshot CT Contusion
___________________________________________________________
___________________________________________________________
_______________
Medic Name/Rank: _____________________________
Provider Level: _____________________________
Unit/Phone # _____________________________