Snakebite Emergency Assessment Form
Please provide detailed information to assist in the emergency assessment and management of a snakebite incident.
Patient Full Name
*
First Name
Last Name
Patient Age
*
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Snakebite Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (address or description)
*
What was the patient doing at the time of the bite?
Is the snake species known or can it be described?
*
Yes, species known or can describe
No, unknown
Location of Bite on Body
*
Please Select
Hand/Arm
Leg/Foot
Torso
Head/Neck
Multiple Locations
Other
Initial Symptoms Observed
*
Pain at bite site
Swelling
Bruising or discoloration
Bleeding
Numbness or tingling
Difficulty breathing
Nausea or vomiting
Dizziness or fainting
Other
Assessment of Clinical Severity
*
No symptoms
1
2
3
4
5
6
7
8
9
Severe symptoms (life-threatening)
10
1 is No symptoms, 10 is Severe symptoms (life-threatening)
Initial First Aid Provided Before Arrival
*
Pressure bandage applied
Immobilization of limb
Tourniquet used
Suction attempted
Washed with water/antiseptic
No first aid provided
Other
Time elapsed from bite to arrival (minutes)
*
Vital Signs at Assessment
Rows
Blood Pressure (mmHg)
Pulse (bpm)
Respiratory Rate (breaths/min)
Temperature (°C)
At Arrival
30 Minutes After Arrival
Additional Notes or Observations (optional)
Submit Assessment
Should be Empty: