Patient Report Form for Medical and Security Documentation
Complete this form with patient and incident details for legal and clinical records.
Basic Details
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Location
*
Incident Type
*
Please Select
Fall
Medical Emergency
Trauma
Road Traffic Collision
Violence/Assault
Other
Attendant Details
Attendant name
*
First Name
Middle Name
Last Name
Role
*
Patient Details
Patient Name
*
First Name
Middle Name
Last Name
Age
*
Gender
*
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Contact Number (if known)
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Complaint
Main Complaint
*
Mechanism of Injury / Illness
*
Primary Survey
Airway status
*
Clear
Partially obstructed
Obstructed
Needs intervention
Other
Breathing status
*
Normal
Shallow
Laboured
Absent
Other
Circulation
*
Normal
Pale
Cold peripheries
Poor perfusion
Major bleeding
Other
Disability (AVPU)
*
Please Select
Alert
Verbal
Pain
Unresponsive
Exposure notes
Observations
Pulse (beats per minute)
*
Blood Pressure
*
Respiratory Rate (breaths per minute)
*
Oxygen Saturation (%)
*
Pupil Size/Reaction
*
Please Select
Equal and reactive
Unequal
Sluggish reaction
Non-reactive
Other
Blood Glucose Level
*
Temperature (optional)
Medical History
Past Medical History
Current Medications
Allergies
Treatment Provided
Oxygen
Nasal cannula
Simple face mask
Non-rebreather mask
Bag-valve mask
Other
Airway management
Positioning
Suction
Jaw thrust
Oropharyngeal airway
Nasopharyngeal airway
Other
Wound care
Dressing applied
Bandaged
Bleeding controlled
Irrigated
Splinted
Other
Medications given, if applicable
Other interventions
Submit PRF
Should be Empty: