Name:

F'EST* Washington University Emergency Support Team

DOB: / / Sex: D Male D Female Call # /

SSN: / / I School: LA EN AR FA BA Grad D Student D Guest Date: / /
Address: D Faculty D Other Dispatch Time:
D Staff
Phone: Arrival Time:
Location: Clear Time:
Chief Com laintlMechanism: Transfer Time:
Time: BP: Pulse: Resps: L Pupils: R Skin: Temp:
i
: ~ ~ Rate:_ _ Rate:_ _ SpOz:_ _% D Normal D D Cool D Pale
: Quality:_ D Regular D Dilated D DWarm D Cyanotic
~ ! i
D Constricted D D Moist D Flushed
! i i D Regular D Shallow
! ! D Sluggish D D Dry D Jaundiced
,! D Irregular D Labored
j i D No-Reaction D D Other D Unremarkable
: :
i
! ! Rate:_ _ Rate: _ _ SpOz:_ _% D Normal D D Cool D Pale
: : Quality:_ D Regular D Dilated D DWarm D Cyanotic
!
!
i! !
! D Regular D Shallow D Constricted D D Moist D Flushed
! ! !
D Irregular D Labored D Sluggish D D Dry D Jaundiced
i
1 ! D No-Reaction D D Other D Unremarkable
i i Rate:- ­ Rate: _ _ SpOz:_ _% D Normal D DCool D Pale
i i
i Quality:_
D Regular D Dilated D DWarm D Cyanotic
i D Regular
D Shallow D Constricted D D Moist D Flushed
:
D Irregular
D Labored D Sluggish D D Dry D Jaundiced
i D No-Reaction D D Other D Unremarkable
Allerg es: Cervical Spine ETOH DYes
DNo
Time C-spine Held: Source:

Released at: Quantity:

LOC DNo Type:

DYes
Meds: Start:
Stop:
Head Pain DNo DYes
Usual Amount
DYes DNo
Neck Pain DNo DYes Usual Rxn
DYes DNo
Back Pain DNo DYes Other Substance:

Nausea DNo DYes

Dizziness DNo Injury:

DYes
Location:

Blurred Vision DNo DYes

Time of Injury:

Numbness DNo DYes PMS:

Tingling DNo DYes Range of Motion:

Fluid in Ears DNo DYes Radiation:

D Taken Normally
PastMed Hx: Peds D Equal DWeak D Unequal
Severity:

D Asthma D Diabetes D None Grips D Equal DWeak D Unequal

D Cardiac D Seizures D Other

FRONT BACK Notes:
R L L R
( ...

;~

1~~

\ 'II' J)
:: ~
\ I \ j<,
I 'II
To: Attending Physician Disposition: Medic 1:
(935-6667) Contacted? D Released to Self EMT:
By: D Police DYes DNo D Released to Other Medic 2:
D Ambulance D Transferred Care o CPRISFA
D Other Equipment Used: D Refused Treatment DEMT:
D Refused Transport Medic 3::
D HIPAA
D Gone on Arrival EMT:
D Disregarded Police:
Name:
F'EST* Washington University Emergency Support Team

I Date: / / I Call # /

To: Attending Physician Disposition: Medic 1:

(935-6667) Contacted? D Released to Self EMT:

By: D Police
DYes DNo D Released to Other Medic 2:

D Ambulance
D Transferred Care o CPRISFA

D Other
D Refused Treatment DEMT:
D Refused Transport Medic 3: :
D HIPAA o Gone on Arrival EMT:
o Disregarded Police: