Wellness Center Treatment Reaction Incident Report
Use this form to report and document any adverse reactions or incidents that occur during treatments at the wellness center.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Full Name of Person Affected
*
First Name
Last Name
Contact Information (Phone or Email)
*
Name of Staff Reporting the Incident
*
First Name
Last Name
Treatment or Service Provided
*
Location of Incident (Room/Area)
*
Describe the Reaction or Incident
*
Symptoms Observed (Select all that apply)
*
Redness or Rash
Swelling
Difficulty Breathing
Dizziness or Fainting
Nausea or Vomiting
Other
Immediate Actions Taken
*
Were there any witnesses?
*
Yes
No
If yes, provide witness names and contact information
Recommendations or Follow-Up Actions Needed
Signature of Staff Reporting
*
Submit Incident Report
Submit Incident Report
Should be Empty: