Prehospital Care Assessment Form
Please complete this form to document the assessment and care provided prior to hospital arrival.
Responder Information
Responder Full Name
*
First Name
Last Name
Responder Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location (Address or Description)
*
Patient Information
Patient Full Name (if known)
First Name
Last Name
Estimated Age
*
Patient Gender
*
Male
Female
Other / Unknown
Chief Complaint / Reason for Call
*
Mechanism of Injury or Nature of Illness
*
Trauma (e.g., fall, accident)
Medical (e.g., chest pain, breathing difficulty)
Other
Initial Patient Status
*
Conscious and Alert
Unconscious
Altered Mental Status
Vital Signs
*
Rows
Time
Blood Pressure (mmHg)
Pulse (bpm)
Respiratory Rate (per min)
Oxygen Saturation (%)
Temperature (°C/°F)
Initial
After Intervention
Assessment Findings
*
Airway Compromised
Breathing Difficulty
Bleeding
Fracture/Suspected Fracture
Burns
Chest Pain
Seizure
Other
Interventions Performed
*
Oxygen Administration
CPR
Defibrillation/AED
Bleeding Control
Splinting/Immobilization
Medication Given
Other
Patient Response to Interventions
*
Improved
No Change
Worsened
Transport Decision
*
Transported to Hospital
Refused Transport
Other (Specify)
Additional Notes / Recommendations
Responder Signature (Required for Documentation)
*
Submit Assessment
Submit Assessment
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