Date

Name Phone Age Sex

First Last
Address If Under 18, Name & Phone of Legal Guardian
Street A t.lBox# Ci State Zi
Activity Past Medical History
DFamily Rec f--::---,.--:-:,.......,.,,--,---------------------------i
o Intramural Patient Medications
oDClub
Recreation
- - - - - Allergies
DSummer Camp f-----------------------r--------------1
DNon-Credit Class Chief ComplaintlMechanism of Injury Times
OPE Class Time ofInjury
o Other Time on Scene
Transport Called
Disposition YO NO
Patient transported to: If Yes: Time called- - -
o Home DSHS DHospital ER: DOther _ Arrived
Transported by: Patient Departed _
DPrivate Vehicle DTaxi DAmbulan,ce (Company/# ) DOther
Vitals Set 1 Set 2 Set 3 L.o.C. Chest Pupillary Response
Time 11213 11213
Pulse/min NWB RI NWB RI NWB RI Responsiveness Breath Sounds LDDD ROOD N
Blood Pressure 11213 LD RD Present LDDD ROOD D
Respirations/min DOD A-Alert LD RD Absent LDDD ROOD C
NSD RI NSD RI NSD RI
Orientated to LD RD Diminished N-Normal Size
Ca ill Refill <2 sec >2 sec <2 sec >2 sec <2 sec >2 sec DO DPerson
Skin Color D-Dilated
oo DPlace Lung Sounds C-Constricted
Tern erature DDDTime LD RD Clear
Moisture LDDD ROOD R
DDDEvent LD RD Rales
Airway PuIselResp. Codes: Equipment Used LDDD ROOD S
Reduced Responses LD RD Rhonchi
o Patent N-Normal LDDD ROOD U
DOD V-Verbal Stimuli LD RD Wheeze R-Reactive
DPartially obstructed W-Weak B-Bounding DDDP-Painful Stimuli LD RD Stridor
DFully obstructed S-Shallow D-Deep S-Sluggish
DDDU-Unresponsive U-Unreactive
R-Regular I-Irregular
Trachea C-Spine Abdomen Quadrant Extremities D+CSMs Extremities DAtraumatic
DMidline DNormal Rigid YOND Reduced!Absent: Present:
DTugging DDeformed Distended YOND Distal Pulse DLU DRU DLL DRL Deformity DLU DRU DLL DRL
LORD Tender YOND Cap-Refill DLU DRU DLL DRL Ecchymosis DLU DRU DLL DRL
DDeviated JVD Palpable Mass YOND
DYDN Sensation DLU DRU DLL DRL Swelling DLU DRU DLL DRL
LORD Guarding YOND Motion DLU DRU DLL DRL Crepitus DLU DRU DLL DRL
Initial Assessment _

Focused Assessment/Patient Interview _

Physical Examination _

Treatment/Ongoing Assessment _

I hereby refuse Dtreatment / Dtransport to a hospital via ambulance and acknowledge that the above mentioned
treatment/transportation was offered and advised by the Emergency Medical Service Provider, Boston University Police, and/or Student Health
Services. I hereby release any such persons, The Department of Physical Education, Recreation, and Dance, and Boston University from liability
for respecting and following my expressed wishes. Patient Signature Witness Signature:--: _
Patient Name (print) Witness Name (print)
EMS Provider Name (Print) _ EMS Provider Signature, _
EMT Certification # Date