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St. Thomas Hospital London

NAME OF PERSON Richard Mill

COMPLETING FORM: Staff ID: 211934

SECTION 1
Date: 05/01/2024 No: 97 From: 101

PATIENT DETAILS (Complete as applicable)

Name: Timotei Bolmada
Sex: M Age: 25 D.O.B 17.12.1998
Home Address: Flat 6 Lakeview,New Bedford Road,Luton,LU3 1NB

DETAILS OF ILLNESS / ACCIDENT

Time/Date of Onset (GMT): 06/11/2023 11:30 Location: Home
The patient fell on the stairs while going down to get ready to go to work

SYMPTOMS & SIGNS (tick, circle or complete all appropriate boxes)

Site(s): Severity: Severe
PAIN:
Character: Aching Pattern: Constant

BLEEDING Site(s): No Severity: N/A

Nausea Vomiting Diarrhoea Cough Breathless or wheezy

Faint Pale Blue Flushed Clammy/Sweating
Hot/feverish Cold Dizzy Weakness Fit/Convulsion
Anxious Confused Aggressive Intoxicated
Rash/spots Where:
Other (specify):

INJURY (tick appropriate box/boxes):

Abrasion Amputation Fracture Bruising Burn
Concussion Cut Dislocation Sprain Foreign Body
Body Part
Head/neck Eye Ear Torso Back
Arm Hand Finger Leg Foot/toe

Pulse: / minute Blood Pressure: mm/Hg

At the last check, the patient has not yet fully recovered and his rest period is extended for a maximum interval of 90 days until the next check
Recomandation: with the obligation to carry out a check every 30 days. / minute
Other observations:

cut-off-portion

TRANSFER OF CARE TO GROUND MEDICAL SERVICES

Name of Casualty: Date and time of onset:

Brief Details of Incident:

Oxygen given: YES / NO If yes, did condition improve? YES / NO

Was casualty unconscious at any time? YES / NO
Defibrillator applied? YES / NO If yes, were any shocks given? YES / NO
MEDICATION ADMINISTERED:

Drug: Dose: Time (GMT)

Any other treatment given:

Crew Member name (CAPITALS): Staff ID: Signature: