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Location: |\n| Date of Birth:\u003Cbr>YEAR MONTH DAY |  |  |  |  |\n| Chief Complaint: |  |  |  | Mechanism of Injury/History of Event: |\n| PRIMARY SURVEY |  |  |  |  |\n| Level of Consciousness |  |  |  |  |\n| Airway |  |  |  |  |\n| Breathing |  |  |  |  |\n| Circulation |  |  |  |  |\n| SIGNS AND SYMPTOMS |  |  |  | O |\n|  |  |  |  | P |\n|  |  |  |  | Q |\n|  |  |  |  | R |\n|  |  |  |  | S |\n|  |  |  |  | T |\n\nSample Patient Care Report Page 1 of 4  \nCopyright © 2012 The Canadian Red Cross Society  \n\n| ALLERGIES |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  None |  |  ASA |  |  Sulpha |  |  |  Penicillin |  |  |  Codeine |  |  |  Other\u003Cbr>(Details in lines below) |  |  Not Determined |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| MEDICATIONS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  None |  |  |  Nitroglycerin |  |  Erectile Dysfunction Drugs |  |  |  |  Ventolin®/Salbutamol |  |  |  Insulin |  |  Birth Control |  |\n|  |  |  |  ASA |  |  Lasix®/Furosemide |  |  |  |  Flovent® |  |  |  Oral Sugar Pills |  |  Not Determined |  |\n|  Other (specify) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| RELEVANT MEDICAL HISTORY |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  Previously Healthy |  |  |  Cardiac |  |  |  Respiratory |  |  Stroke/TIA |  |  |  Seizures |  |  |  Falls |  |\n|  |  |  |  Diabetes |  |  |  Psychiatric |  |  Cancer |  |  |  High Blood Pressure |  |  |  Not Determined |  |\n|  | Other (specify) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| LAST MEAL |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| EVENTS PRIOR |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| HEAD-TO-TOE PHYSICAL EXAMINATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| General Appearance: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Head/Neck: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Chest: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Abdomen: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Back/Pelvis: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Extremities: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Other: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nSample Patient Care Report Page 2 of 4  \nCopyright © 2012 The Canadian Red Cross Society  \n\n| VITAL SIGNS |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| TIME |  |  |  |  |\n| PULSE |  |  |  |  |\n| RESPIRATIONS |  |  |  |  |\n| BLOOD PRESSURE |  |  |  |  |\n| SKIN | Colour |  |  |  |\n|  | Temperature |  |  |  |\n|  | Condition |  |  |  |\n| PUPILS | Right |  |  |  |\n|  | Left |  |  |  |\n| LOC | Alert and Responsive |  |  |  |\n|  | Responsive But Not Alert |  |  |  |\n|  | Unresponsive (Unconscious) |  |  |  |\n| GCS |  |  |  |  |\n| BGL |  |  |  |  |\n\n\n| TREATMENT |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| TIME | CARE PROVIDED |  |  |  | RESPONDER\u003Cbr>INITIALS |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  OXYGEN\u003Cbr>USED |  Nasal Cannula |  NRB |  Simple |  BVM | Flow Rate: LPM |\n| CARDIAC\u003Cbr>ARREST: |  AED Used |  | Minutes of CPR Done: |  |  |\n|  | \\# Shocks: |  | \\# No Shocks: |  |  |\n\n\n| NOTES |\n| --- |\n|  |\n|  |\n|  |\n|  |\n\n\n| OUTCOME |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Destination: |  Return to Activity |  Home |  To Physician |  To Hospital |\n|  |  Other: |  |  |  |\n| By: |  Private Car |  Taxi |  Police (Badge \\#: ) |  |\n|  |  Paramedics (Unit \\#: ) |  |  Other: |  |\n\nINJURY LOCATION DIAGRAM  \n| RESPONDER 1 | NAME | SIGNATURE | TIME | DATE |\n| --- | --- | --- | --- | --- |\n| RE","cbCaihJb7k0sXz0H","https://ap.wps.com/l/cbCaihJb7k0sXz0H","pdf",134513,"English","# Primary Survey\n# Signs and Symptoms\n# Allergies and Medications\n# Relevant Medical History\n# Last Meal and Events Prior\n# Head-to-Toe Physical Examination\n# Vital Signs\n# Treatment and Care Provided\n# Notes and Outcome\n# Injury Location Diagram\n# Refusal of Treatment Section","[{\"question\":\"What information does the primary survey section collect?\",\"answer\":\"It records level of consciousness and assesses airway, breathing, and circulation, supporting rapid triage documentation.\"},{\"question\":\"Where are allergies, medications, and medical history documented?\",\"answer\":\"Dedicated sections cover allergies, current medications, and relevant medical history such as cardiac, respiratory, diabetes, and other conditions.\"},{\"question\":\"What is included in the refusal of treatment section?\",\"answer\":\"The template includes instructions for completing the refusal content, a statement of received first-aid and wish to refuse further treatment, and required patient/substitute decision-maker and witness details.\"}]","Sample Patient Care Report - Form | PDF",1790147968]