AFS Injury Incident Form – Medic AFS – Patient Injury Form AFS – Injury Incident Form – Completed by Trainer attending to any injury Date(Required) DD slash MM slash YYYY Location(Required) Time(Required) Hours : Minutes Medic's Name(Required) First Last Name of Injured Person(Required) First Last Gender(Required)MaleFemaleNon-BinaryDate of Birth(Required) MM slash DD slash YYYY PhoneAssociation(Required) Age Group(Required) Allergies(Required)YesNoNot SureList Allergies Noted Medication(Required)YesNoNot SureList Medications Medical History(Required) Not Known None Asthma Cardiac Diabetes Epilepsy Hypertension Other? Observations Taken?(Required)YesNot requiredTime 1st Ob Hours : Minutes Breathing Normal Abnormally Other Pulse 02 LevelBlood Pressure Concious Awake Verbal Pain Unresponsive Pain Other Obs/Actions Taken(Required)YesNoe.g. Temp, BGL, MedicationNote Other Obs Taken *Repeat Observations if required (use previous fields to add repeat obsYesRepeat x 1Repeat x 2Repeat x 3Repeat x 4Repeat more than x 4Not requiredHistory of Injury/Illness(Required)*Describe any Signs and SymptomsWhich area of the body is the injury?(Required) Front Right Front Left Front Middle Back RIght Back Left Back Middle Which Body Part is the injury?(Required)HeadNoseEyeEarNeckArm UpperArm LowerHandFingersShoulderElbowWristChestStomach/AbdominalHipsBackLeg UpperLeg LowerKneeAnkleFootToeSpine Assessment Performed?(Required)YesNoPreferable however Not possibleSpine TendernessYesNoHead Assessment Performed?(Required)YesNoPreferable however Not possibleInclude comments in relation to actions or advice given Concussion/Spinal AssessmentLoss of ConciousnessYesNoPEARLYesNoBalance/Motor CoordinationYesNoRecallYesNoApply Concussion AssessmentGlasgow Coma Scale GCSMaddocks ScoreOtherRest-Ice Compression-Elevation(Required)YesNoMedication Taken(Required)YesNoTime Taken Hours : Minutes Dose Refused Treatment(Required)YesNoRefused Treatment – Name and Details of Witness Complete Name and Phone Number Offered Ambulance(Required)YesNoDeclined AmbulanceYesNoContinued Treatment Recommended(Required)YesNot RequiredInstruction to cease recommended treatment if symptoms increase or other signs appear Provide description of adviceDischarged accompaniedContinue Activity Only by – SpectatorContinue Activity Only – by own DoctorContinue Activity Only- to HospitalDischarged byAmbulanceOwn carWalking with assistance/assigned carerWalking aloneOtherTime Out : Completed Treatment(Required) Hours : Minutes Add image if appropriateAccepted file types: jpg, jpeg, png, gif.
