EmailMe Form - PATIENT REPORT FORM

PARAMEDIC INFORMATION

The treating Paramedic must please complete this section.

Paramedic Name and Surname *

First Last

HPCSA Suffix Code

HPCSA Registration Number (Without Code) *

Paramedic Cell Phone *

### - ### - ####

Date Time *

DD / MM / YYYY HH : MM AM/PM

Current Date and Time of this report

PATIENT INFORMATION

Paramedic to complete Personal Information

Gender *

Male

Female

Pateint Name *

First Last

ID Number or Birth Date (YYMMDD)

Refuse Hospital Treatment (RHT) *

No

Yes

Signature refusing any medical treatment.

Clear

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Cell Phone

### - ### - ####

Home Phone

### - ### - ####

Work Phone

### - ### - ####

Email

MEDICAL AID INFORMATION

Please complete where applicable

Medical Aid Scheme Name

Medical Aid Type

Medical Aid Number

NEXT-OF-KIN INFORMATION

Please complete where applicable

Name and Surname of Next-Of-Kin

First Last

Next-Of-Kin Cell Phone

### - ### - ####

PATIENT PRIMARY ASSESSMENT

Kindly complete the Medical Incident Report here

BP (Systolic)

BP (Diastolic)

Pulse

Glucose

Respiratory Rate (B/Min)

Temperature

Airway Assessment (Oscillating)

C-Spine Assessment

PATIENT SECONDARY ASSESSMENT

Kindly complete the Medical Incident Report here

Accident Type *

Medical

Sports

Trauma Accident

Patient's LOC (A.V.P.U.) *

Alert

Voice

Pain

Unresponsive

Patient Transport Priority (C.U.P.S.) *

Critical

Unstable

Potentially Unstable

Stable

Mechanism Of Injury (MOI)

SECONDARY SURVEY

Patient's Pupil Reactions *

Reacting

Not Reacting

Patient's Pupils *

Normal

Constricted

Dialated

Patient's Skin Colour *

Patient's Skin Temp *

Warm

Cool

Hot

Patient's Skin Moisture *

Normal

Moist

Dry

S.A.M.P.L.E. Assessment

Signs & Symptoms
Allergies
Medication
Past Medical History
Last Meal Intake
Events to Injury

Patient Full Assessment (Comments and Remarks)

Paramedic's Treatment (Comments and Remarks)

GLASCOW COMA SCALE ASSESSMENT

GLASGOW COMA SCORE (EYE OPENING) *

GLASGOW COMA SCORE (VERBAL RESPONSE) *

GLASGOW COMA SCORE (MOTOR RESPONSE) *

PATIENT HAND OVER TO AMBULANCE/HOSPITAL

Patient Handed Over to who? Full names

Paramedic's Handover (Comments and Remarks)

Signature of Medical Personnel

Clear