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PATIENT CARE REPORT

Incident Date:
NAME:
Incident Time:
Incident Location: Address:
Nature of Injury: Date of Birth Age: Sex: Civil Status:
Extrication Time:

INITIAL EXAMINATION Chief Complaint:

Brief History:

Tuberculosis Hypertension Diabetes Stroke

Seizures Asthma COVID-19 Infection Heart Disease

VITAL SIGNS
CPR Done? Yes No
BP: Temp: PR: RR: O2 Sat:
Time Started:

Undergone COVID-19 Test for the past 14 days?

EYES
Yes: No: RTPCR: RAT:
PERRLA: Constricted:
Dilated: Non-reactive
COVID 19 Vaccination Status
Unvaccinated Fully Vaccinated Booster
SKIN

warm Dry Moist

Cold Flushed Pale
RESPONDER ON DUTY