Wellington Caving Group | Information / Victim Report browse

NZSS Accident Victim Report (One sheet for each victim)

Version 1999 November Corrections and updates to the webmaster please

1. Name :

Age :

Sex : F / M

Next of Kin :
(if known)

Address :

Phone :

Medical Condition (Delete not applicable)

2. Head

Has patient had a head injury?	Yes / No / Don't know
Is patient concious?	Yes / No
Has patient been UNconcious?	Yes / No
Does the patient seem to be getting	Better / Worse
Is / Was patient	Dizzy / Seeing stars / Disoriented
Is / Was patient vomiting	Yes / No
Is patient coughing up blood?	Yes / No	Bright / Dark / Frothy
Is any fluid coming from ears?	Yes / No	Colour
Is any fluid coming from nose?	Yes / No	Colour
What is colour of face?			(was patient looked at in carbide/electric light)
What is colour of lips?

3. Breathing

Any trouble breathing?

Yes / No

4. Pain

Is there any pain?		Yes / No
Where?

5. Breaks

or suspected breaks (include neck and spine)
Where?	Any major deformity?	Any loss of sensation?	Any loss of movement?

6. Bleeding

7. Other

Pulse Rate
Can patient walk or move in any way?	Yes / No
Any known medical conditions? (eg. diabetes, epilepsy, asthma)		Check for Medic-Alert
When did the patient last eat?	Drink?
What is the risk of Hypothermia?	Low / Medium / High	Is the Patient Wet / Dry?
How is the patient dressed?
What action has already been taken? (eg. medication / comfort)

8. General
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