Triage Score

Pre-Hospital
12345 Assessment Sheet
Date: Time in: Patient Name: Age: Sex:

Presenting Problem:

Allergies: Medications:

Medical History
⃝ None Known ⃝ Asthma ⃝ Diabetes ⃝ Epilepsy
⃝ Not Available ⃝ Cardiac ⃝ Hypertension ⃝ Medi Alert
⃝ Anti-Depressants (Used Recently ⃝ Yes / ⃝ No) ⃝ Other
Mark injuries on the diagram using the legend
Airway Normal Abnormal
A Abrasion
Bl Bleeding
Breathing Normal Abnormal
Bu Burns
C Contusion
Pulse Normal Abnormal
D Deformity
F Fracture
Perfusion Normal Abnormal
L Laceration
P Pain
Pt Aggressive / Agitated No Yes
S Swelling
T Tenderness
BSL mmol/L

AVPU / Pupil Pupil Pupil Pulse Resp Rate Pain

Time BP Temp SpO2
GCS L Size R Size Reactive per minute per minute Score
Recommended clinical criteria to trigger immediate senior clinician review
< 100 or < 35.5 C
Any decrease in level of consciousness < 50 < 12 < 95% on
> 140 or
or new confusion or > 100 or > 22 Room Air
systolic > 38 C

Eye opening Response Verbal Response Motor Response

4 - Spontaneous 5 - Orientated 6 – Obeys Commands
3 - To Sound 4 - Confused 5 – Purposeful movement to stimuli
2 - To pain (not to face) 3 – Inappropriate Words 4 – Withdraws to pain
1 - No Response 2 – Incomprehensible Speech 3 – Flexion
1 – No Response 2 – Extension
1 – No Response
This template was developed by Mardi Gras Medical and is being used with their permission with thanks
Treatment Provided
Medication / Fluids / O2 / Given by
Time Dose Route Response
Intervention Sign & Print

Comments:

Discharged: ⃝ Returned to Event ⃝ Leaving the Venue ⃝ Ambulance (Car #_______)

Patient Friend / Contact Name: Contact Phone Number:

Time Discharged from Medical: Treatment completed by:

Case Discussed with: (Sign and Print name)
SHPN (CPH) 190492

This template was developed by Mardi Gras Medical and is being used with their permission with thanks