Region ________________________ Injury Registry Fax: 741-7048, 743- 6076, 743- 1937 Hospital ________________________ Name Residence Date Date Type of Injury Diagnosis Type of Liquor Given(3) Disposition(4) (Family (House #, (mm/dd) (mm/dd) (If other diagnosis, to include Firecracker Intoxica- Name, Street, Time of Time of Involve- pls. specify) nature tion(2) First Age/Sex Bgy., Injury Consult ment (1) and site Name, Mun/City, Place of Middle Prov.) Injury Initial) DOI: DOC: [ ] Blast/Burn WITH [ ] Yes [ ] ATS [ ] Discharged [ ] Active Amputation [ ] No [] [ ] Admitted TOI: TOC: [ ] Blast/Burn NO Toxoid [ ] Hama [] Amputation [ ] None [ ] Died Passive [ ] Eye injury [] [ ] Transferred Place of injury: [ ] Watusi ingestion Others [ ] GSW Stray Bullet ______________________ PHONE: [ ] Tetanus [ ] Others _________________ DOI: DOC: [ ] Blast/Burn WITH [ ] Yes [ ] ATS [ ] Discharged [ ] Active Amputation [ ] No [] [ ] Admitted TOI: TOC: [ ] Blast/Burn NO Toxoid [ ] Hama [] Amputation [ ] None [ ] Died Passive [ ] Eye injury [] [ ] Transferred Place of injury: [ ] Watusi ingestion Others [ ] GSW Stray Bullet ______________________ PHONE: [ ] Tetanus [ ] Others _________________ DOI: DOC: [ ] Blast/Burn WITH [ ] Yes [ ] ATS [ ] Discharged [ ] Active Amputation [ ] No [] [ ] Admitted TOI: TOC: [ ] Blast/Burn NO Toxoid [ ] Hama [] Amputation [ ] None [ ] Died Passive [ ] Eye injury [] [ ] Transferred Place of injury: [ ] Watusi ingestion Others [ ] GSW Stray Bullet ______________________ PHONE: [ ] Tetanus [ ] Others _________________ DOI: DOC: [ ] Blast/Burn WITH [ ] Yes [ ] ATS [ ] Discharged [ ] Active Amputation [ ] No [] [ ] Admitted TOI: TOC: [ ] Blast/Burn NO Toxoid [ ] Hama [] Amputation [ ] None [ ] Died Passive [ ] Eye injury [] [ ] Transferred Place of injury: [ ] Watusi ingestion Others [ ] GSW Stray Bullet ______________________ PHONE: [ ] Tetanus [ ] Others _________________ DOI: DOC: [ ] Blast/Burn WITH [] [ ] ATS [ ] Discharged [] Amputation Yes [] [ ] Admitted TOI: TOC: Active [ ] Blast/Burn NO [] Toxoid [ ] Hama Amputation No [] [ ] Died [] [ ] Eye injury None [ ] Transferred Place of Passive [ ] Watusi ingestion [] injury: [ ] GSW Stray Bullet Others ______________________ PHONE: [ ] Tetanus [ ] Others _________________ DOI: DOC: [ ] Blast/Burn WITH [] [ ] ATS [ ] Discharged [] Amputation Yes [] [ ] Admitted TOI: TOC: Active [ ] Blast/Burn NO [] Toxoid [ ] Hama Amputation No [] [ ] Died [] [ ] Eye injury None [ ] Transferred Place of Passive [ ] Watusi ingestion [] injury: [ ] GSW Stray Bullet Others ______________________ PHONE: [ ] Tetanus [ ] Others _________________ DOI: DOC: [ ] Blast/Burn WITH [] [ ] ATS [ ] Discharged [] Amputation Yes [] [ ] Admitted Active [ ] Blast/Burn NO [] Toxoid [ ] Hama Amputation No [] [ ] Died [] [ ] Eye injury None [ ] Transferred Passive [ ] Watusi ingestion [] [ ] GSW Stray Bullet Others ______________________ PHONE: [ ] Tetanus [ ] Others _________________
1.Involvement 2. Liquor 3.Given 4.Disposition
Prepared by: intoxication ATS= Anti Discharge= Active= injured while lighting or holding Yes- under the Tetanus Serum Discharged improve/ firecracker influence of Toxoid= recovered Signature over alcohol (+AB) Tetanus toxoid Admitted= Admitted in Passive= injured while watching a No- not under None= ATS or the hospital Printed Name firecracker being lighted or passing by the influence of Tetanus toxoid HAMA= Home against alcohol nogiven medical advice Died