Trauma Care Patient Record Form
Please complete this form to record details of a trauma-related patient visit. Do not include sensitive identifiers or confidential information.
Patient Full Name
*
First Name
Last Name
Patient Age
*
Gender
*
Male
Female
Other
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Visit
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Type of Incident
*
Please Select
Road Traffic Accident
Fall
Assault
Burn
Other
Brief Description of Incident
*
Injury Type
*
Fracture
Laceration
Contusion
Head Injury
Other
Initial Assessment Notes
Treatment Provided
Submit Record
Should be Empty: