PATIENT ENCOUNTER FORM

Event :_..l.'.t&fo~-=-~__:__________
DATE & TIME (24hR) dl)~;,/2,ov..-
last Nan,e . ·-;-,- · - - - . - - - - - - - - - - CLINICAL IMPRESSION OF CARE PROVIDER
First N ·--.t:\-V ....1'.:._::~:..:..:..:\'-(~£L__ _ _ _ _ __ Abrasiondental hypotermla
an,e :
Phone D Blister D Di~cation D Intoxication
Age D Chest Pain [il.ffizzlness D Laceration
DOB D Female D Concussion D Sprain/Strain
0 Contusr O Hrerthermia
Family Physician :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Other b:Juw-r, Wtulc<,.ut'"'
PATIENT CATEGORY_\J_\°'\;__;;C,:::...w=..\f\~-------- MEDICATION or IV GIVEN
A=Alhlete, E=Event Staff, P=Performer, S=Spectator, U=Unknown
Time: Medication/IV Provider Name :

-----------------
PARTICIPANT ID
\ t-j .}O OA.¾ ~'t:.vl. ~"' r'\ J> ... ,.~\Sc-. ely '-'\'V'CJ I,\
(Race/Bib Number)
TRIANGLE ACUITY SCALE"'*
0 Black D Red O Yellow D Red
TREATMENT & SERVICES PROVIDED
PRESENTING COMPLAINT
0 Antacid D Splint/Taping/Tensor
D Counselling D Stretching
D Ibuprofen D Tylenol
D Immobilization Ovaseline
0 R.I.C.E. D Wound Manac,_ement
D Other QVl..d'.C\'t,k,v\""'-""'
D Other_ _ _ _ __ D Other_ _ _ _ __
Past History,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

DISCHARGE ACUITY SCALE**

------
Medications_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
0 Black O Red O Red ~en

Allergies._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
FOLLO~P DISPOSITION
~ n t Medical Team ~urned to Event/work
D Left Event (Private Vehicle)
VITAL SIGNS D Family Physician/Clinic D Left Event (taxi)
#1 #2 #3 D Other_ _ _ _ __ D Left Event (event staff)
R
nme 11lt: D Ambulance Transport
L A L Temp.
5 D Air Evacuation
Pulse i1t'
B.P.
~- D Other_ _ _ _ _ __
R.R. _jQ___
Sa02 .fjJ_ DISCHARGE INSTRUCTIONS V\I\ a£<. VI. ~Vv \v,
Glucose
GCS _l_L_ ADDITIONAL NOTES._ _ _ _ _ _ _ _ _ _ _ __
PHYSICAL FINDINGS
V\..C)f'M..c,

Did the care provided on site prevent a visit to 3J)81her medic

facility (i.e. hospital, clinic, family doctor) ? '!:f Yes D No
•oos, PHN, Family Physician (Optional) MGMPt. ID:
••rriage/Dlschar9e Acuitv Scale Level LEVEL OF TRAININF OF CARE PROVIDER.. _ _ _ _ _ __

\¼kcc,\ i~V\Q I UQ.v,

Black/Deceased-obvious non-survivablle injury
Red/emergent-Critical, resucltation, Chest Pain, Collapse LOCATION CARE WAS PROVIDED
YellowNrgent-Overdose no ABC compromise, SOB
Grun/Minor-Assessment requ ired, wound ca re, prescriptions DISCHARGETIME_ _ \_!j_...::;3~)~--------:----
Name of Attendant (Please PRINT) dv-. Mec;:A IQ lt1tt_ ' } ~
Whl~/Dlspensary- Product ~uests, Costumer Cervise RAID :

..Lewi of Tralnlnc of care Provider

PCP, SFA, OFA, EIII~, LPN, RN, NP, MD, Chlro, Physio, etc Signature of Attendant._ _ _ _ _.,.~..:::.
..::_-=~c-------