Patient Casualty / Monitoring Form

Location: Gumshoe Sporting Fields		Date: 28/10/1999	Time: 02:15pm
Name: John Smith		DOB: 30/11/1952	Sex: Male
Address: 1 Smith Drive, Armidale NSW 2350			Phone: 6771 2345
Staff / Student / [Visitor]	(please circle one)
Accident History: Patient tripped whilst playing tennis, slid along concrete surface.
Allergies / Medication: Peanuts. Penicillin
Assessment
Injuries/Symptoms/Signs
First aid assessment: Patient is in moderate pain , suffering slight shock, has moderate abrasions.
Action taken: Abrasions have been treated to stop infection. Patient is lying down with legs slightly elevated and reassurance given to combat shock.

Observations
Time hh/mm		02.20pm	02.30pm	hh/mm	hh/mm	hh/mm	hh/mm	hh/mm	hh/mm
Level of Consciousness	Fully Conscious	YES	YES
	Drowsy
	Unconscious
Pulse	Rate	82	75
	Description	STRONG	STRONG
Resp	Rate	26	20
	Description	REGULAR	REGULAR
Pupils Reactive/Equal	Right/ Left	EQUAL	EQUAL
Other Observations:		Patient felt slightly nauseated
First Aider: Jo Bloe						Date:28/10/1999
Signature: JBloe						Time: 02:45pm