INCIDENT REPORT FORM

Date Location Time

Patient’s Name Gender Age

Patient’s address Contact no.

Time of incident Nature of incident

Place of incident Date of Incident

Witness’ Name Relation to the Victim Contact no.

Past medical history Not known Asthma Cardiac Problem Diabetic

(patient) Surgery Epilepsy Hypertension
Other __________________ Allergy

Conscious level
Time Respiratory Pulse Blood Alert Voice Pain Other
Rate Rate Pressure Unconscious Observations
(see information below
Eye Verbal Motor
Opening Response Response

Injury Description:
Treatment
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Name of First aider and Signature

Level of Consciousness
Types of Injury
Behavior Abrasion
Response Laceration
Score
Eye Bleeding
Spontaneously Pain 4
To speechBurns Swelling
3
Opening To pain Contusion 2
Response Tenderness
No response 1
Deformity Puncture
Oriented to time, place, and person 5
Best Confused
Fracture 4
Verbal Inappropriate words 3
Response Incomprehensible sounds 2
No response 1
Obey commands 6
Best Moves to localized pain 5
Flexion withdrawal from pain 4
Motor Abnormal flexion (decorticate) 3
Response Abnormal extension (decerebrate) 2
No response 1