EMT

Scene Size-up
Dispatched at: 
[text name="dispatch" default=""]
Arrived at:[text name="arrive" default=""]
Scene Safe?[checkbox name="scene safe?" value="Yes|No"]
BSI Used [checkbox name="bsi" value="Gloves|Gown|Eye protection"]
Number of pts [text name="pts#" default=""]
Additional Resources Used[checkbox name="addresources" value="None|ALS|Fire|PD"]
C-Spine Stabilized?[checkbox name="c-spine" value="Yes|No"]
Sex: [checkbox name="sex" value="Male|Female"]
Age: [text name="age" default=""]

Initial Assessment
[checkbox name="stable/unstable" value="Stable|Unstable|Not yet unstable"]
AVPU:
[checkbox name="avpu" value="Alert|Verbal|Painful|Unresponsive"]
C/C [text name="c/c" default=""]
Airway [checkbox name="ariway" value="Patent|Obstructed"]
Breathing[checkbox name="breathing" value="Self maintained|Assisted"]
Circulation 
[checkbox name="circulation" value="No bleeding|Bleeding"]
Transport [checkbox name="trasnport" value="Emergent|Non-emergent"]

Secondary Assessment
S/S [text name="s/s" default=""]
O [text name="o" default=""]
P [text name="p" default=""]
Q [text name="q" default=""]
R [text name="r" default=""]
S [text name="s" default=""]
T [text name="t" default=""]
A [text name="a" default=""]
M [text name="m" default=""]
P [text name="p" default=""]
L [text name="l" default=""]
E [text name="e" default=""]

Medical 
Pulmonary [checkbox name="pulm" value="WNL"][text name="pulmt" default=""]
Cardiovascular[checkbox name="cardio" value="WNL"][text name="cardiot" default=""]
Neurological [checkbox name="neuro" value="WNL"][text name="neurot" default=""]
Skin[checkbox name="skin" value="WPD"][text name="skint" default=""]
GI/GU[checkbox name="gi/gu" value="WNL"][text name="gi/gut" default=""]
Reproductive[checkbox name="repor" value="WNL"][text name="reprot" default=""]
Psychological/Social[checkbox name="psych/soc" value="WNL"][text name="psych/soct" default=""]

Trauma
[checklist name="DCAPBTLS" value="Deformities/discolorations|Contustions|Abrasions|Punctures/penetration|Burns|Tenderness|Lacerations|Swelling"]
HEENT [text name="heent" default=""]
Chest [text name="chest" default=""]
Abdo [text name="abdo" default=""]
Back [text name="back" default=""]
Extremities [text name="extremities" default=""]

Vitals
Pain [text name="pain" default=""]/10
Resp [text name="resp" default=""]
Skin [text name="skinv" default=""]
O2 [text name="o2" default=""]
Pulse [text name="pulse" default=""]
BP [text name="bp" default=""]
Glucose [text name="glucose" default=""]

Treatments [textarea name="rx" default=""]
Transport [textarea name="transports" default=""]

Summary
[var name="c/c"][var name="avpu"][var name="airway"][var name="breathing"][var name="circulation"][var name="transport"][var name="S/S"][var name="o"][var name="p"][var name="q"][var name="r"][var name="s"][var name="t"][var name="a"][var name="m"][var name="p"][var name="l"][var name="e"][var name="pulm"][var name="pulmt"][var name="cardio"][var name="cardiot"][var name="neuro"][var name="neurot"][var name="skin"][var name="skint"][var name="gi/gu"][var name="gi/gut"][var name="psych/soc"][var name="psych/soct"][var name="DCAPBTLS"][var name="heent"][var name="chest"][var name="abdo"][var name="back"][var name="extremities"][var name="pain"][var name="resp"][var name="skinv"][var name="o2"][var name="pulse"][var name="bp"][var name="glucose"][var name="rx"][var name="transports"]