Professional Documents
Culture Documents
REPORT HEAT
Patient
Nation
Name/Rank: _____________________________
□ USA □ CONTRACTOR COLD
SSN:
□ US
_________________________________________
Date of Birth:
□ Host
□ USMC □ EPW
MEDEVAC PATIENT REPORT
___________________________________
Nation
□ USAF □ OTHER___________
BITE / STING
OTHER
( )Male
□ Enemy ( )Female
□ USN _ __________________
□ Coalition
MTF DESTINATION: UNIT: DATE/TIME:
- -
Wounded by:
□ US/Coalition
□ Enemy
□ Civilian
□ Accident
□ Other_______________________________
Mechanism of Injury: STAB BURN HEAT
GSW COLD
BLAST CRUSH
BLUNT TRAUMA BITE / STING
VEHICLE ACCIDENT FALL
SINGLE FRAGMENT OTHER ______
CARDIAC MEDICAL
MULTI FRAGMENT ________________________
Not Worn
Worn
Struck
Penetrated
REPORT
MEDICATIONS(NAME,DOSE,TIME)________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___REPORT__________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
AM Amputation BL Bleeding D Deformity ___________________________________________________________
AV Avulsion B Burn F Foreign Body ___________________________________________________________
L Laceration P Puncture FX Fracture ___________________________________________________________
S Stab Wound GSW Gunshot CT Contusion
___________________________________________________________
___________________________________________________________
_______________
Medic Name/Rank: _____________________________
Provider Level: _____________________________
Unit/Phone # _____________________________