Occupational First Aid Patient Assessment Form
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1OCCUPATIONAL FIRST AID
PATIENT ASSESSMENT
DATE AND TIME OF ILLNESS / INJURY
AM / PM
DATE AND TIME REPORTED TO FIRST AID
AM / PM
TIME OF ARRIVAL AT FIRST AID (WALK IN)
AM / PM
TIME ON SCENE (IF APPLICABLE)
AM / PM
EMPLOYEE NAME
DATE OF BIRTH
D
M
Y
EMPLOYER NAME
EMPLOYER PHONE NUMBER
EMPLOYEE’S DOCTOR
CONTACT PERSON
EYE OPENING RESPONSE
BEST VERBAL RESPONSE
BEST MOTOR RESPONSE
4 SPONTANEOUSLY
5 ORIENTED
6 OBEYS COMMANDS
GLASGOW COMA SCALE
3 SPEECH
4 CONFUSED
5 LOCALIZES PAIN
2 TO PAIN
3 INAPPROPRIATE WORDS
4 WITHDRAWS FROM PAIN
1 NO RESPONSE
2 INCOMPREHENSIBLE SOUNDS
3 FLEX TO PAIN (DECORTICATE)
1 NO RESPONSE
2 EXTENDS TO PAIN (DECEREBRATE)
1 NO RESPONSE
PATIENTS CHIEF COMPLAINT
VITAL SIGNS
TIME
TIME
TIME
TIME
RESPIRATIONS
MECHANISM OF INJURY / HISTORY OF ILLNESS
PULSE
E
TOTAL
E
TOTAL
E
TOTAL
E
TOTAL
LOC / GCS
V
V
V
V
M
M
M
M
PHYSICAL FINDINGS
PUPIL SIZE &
L
R
L
R
L
R
L
R
REACTION
+ / -
SKIN
ALLERGIES
PLEASE MARK INJURED OR EXPOSED AREA
MEDICATIONS
INTERVENTIONS (PLEASE CHECK)
❐ AIRWAY CLEARED
❐ MAINTAINED
❐ OROPHARYNGEAL AIRWAY
❐ VENTILATED
❐ PKT. MASK
❐ BVM
❐ CONTROLLED BLEEDING
❐ OXYGEN ADMINISTERED
LPM__________
DEFINITIVE TREATMENTS (PLEASE CHECK)
❐ TRACTION
❐ SPLINTED
❐
IMMOBILIZED
❐ SPINAL IMMOBILIZATION
❐ ADDITIONAL TREATMENTS (PLEASE EXPLAIN)
RECOMMENDATIONS
❐ RETURN TO WORK
❐ FIRST AID FOLLOW UP
❐ MEDICAL AID
TRANSPORTED BY (PLEASE CHECK)
CHANGES IN PATIENTS CONDITION (PLEASE EXPLAIN)
❐ ETV
❐ INDUSTRIAL AMBULANCE
❐ B.C. AMBULANCE SERVICE
❐ AIR EVACUATION
❐ OTHER (PLEASE EXPLAIN)
F.A.A. NAME (PLEASE PRINT)
F.A.A. SIGNATURE
OFA CERTIFICATE #
OFA LEVEL
❐ 1
❐ TE
❐ 2
❐ 3
NAME OF WITNESSES (PLEASE PRINT)
EMPLOYER MAILING ADDRESS
STREET / AVENUE
EMPLOYEE SIGNATURE
CITY / TOWN
POSTAL CODE
55M60
(R01/06)
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