Paramedic Patient Assessment

DISPATCHED FOR:[textarea name="dispatch" default=" "]

RESPONSE:
[checkbox name="RESPONSE" value="EMERGENT.|NONEMERGENT.|LIGHTS/SIRENS.|LIGHTS NO SIRENS.|NO LIGHTS NO SIRENS.|UPGRADED TO EMERGENT.|DOWNGRADED TO NONEMERGENT."]

DISPATCH PRIORITY: 
[checkbox name="Alpha" value="A|B|C|D|E"]

DISPATCHED Level: 
[checkbox name="LEVEL" value="priority 1|priority 2|priority 3| priority 4| priority 5"]

Hospital Destination: [text name="Hospital Destination" default=" "]
Reason For Hospital Destinaton: [text name="Reason For Hospital Destination" default=" "]
===================================================================================

**************
* COVID - 19 *
**************

Close contact with person with confirmed or suspected COVID-19: [select name="variable_2" value="NO|YES"]
Travel to high risk COVID-19 areas per current local guidance: [select name="variable_3" value="NO|YES"]

SYMPTOMS:
Shortness of breath:[select name="variable_1" value="NO|YES"]
Cough: [select name="variable_2" value="NO|YES"]
Fever >100.4: [select name="variable_3" value="NO|YES"]
Sore Throat: [select name="variable_4" value="NO|YES"]
Loss of Smell: [select name="variable_5" value="NO|YES"]
Nausea: [select name="variable_6" value="NO|YES"]
Vomiting: [select name="variable_7" value="NO|YES"]
Flue like symptoms: [select name="variable_8" value="NO|YES"]
Onset of first symptom:[date name="variable_1" default="05/04/2020"]
Quarantine: [select name="Quarantineintiated" value="Yes |No"] 
Isolation: [select name="Isolationintiated" value="Yes |No"]

Symptoms are [select name="variable_1"name="variable_2"name="variable_3"name="variable_3"name=variable_4"name=variable_5"name=variable_5"name=variable_6"name="variable_7"name=variable_8" value="IMPROVING|WORSENING|STAYING THE SAME"] since onset.

**********************************************************************************
*** SUBJECTIVE ***
**********************************************************************************

===================================================================================
Arrived to find [text name="variable_1" default=" "] 
Gender [checkbox name="Gender" value="Male|Female|Refused to Answer"]
Age [text name="variable_1" default=" "]
===================================================================================
Patient complained of: [textarea name="The Patient complained of" default="sample text"]
Patient DENIED:[textarea name="The Patient denied the following:" default="sample text"]
Patient's Medical History: [textarea name="The Patient's Medical History is" default="sample text"]
Patient's Allergies: [textarea name="The Patient's Allergies are" default="sample text"]
Patient's Medications: [textarea name="The Patient's Medications are" default="sample text"] 
===================================================================================
Onset: [text name="Onset:" default="sample text"]
Location: [text name="Location:" default="sample text"]
Duration:[text name="Duration:" default="sample text"]
Characterization:[text name="Characterization:" default="sample text"]
Alleviating and Aggravating Factors:[text name="Alleviating and Aggravating Factors default="sample text"]
Radiation:[text name="Radiation" default="sample text"]
Time:[text name="Time" default="sample text"]
Severity:[text name="Severity" default="sample text"]

===================================================================================

Admits or Denies 

Headache[select name="variable_1" value="NO|YES"]
Dizziness[select name="variable_1" value="NO|YES"]
Blurred Vision[select name="variable_1" value="NO|YES"]
Nausea[select name="variable_1" value="NO|YES"]
Vomiting[select name="variable_1" value="NO|YES"]
Diarrhea[select name="variable_1" value="NO|YES"]
Chest Pain[select name="variable_1" value="NO|YES"]
Difficulty Breathing[select name="variable_1" value="NO|YES"]
Abdominal Pain[select name="variable_1" value="NO|YES"]
Pelvic Pain[select name="variable_1" value="NO|YES"] 
Leg Pain[select name="variable_1" value="NO|YES"]
Arm Pain[select name="variable_1" value="NO|YES"]
Back Pain[select name="variable_1" value="NO|YES"]
Neck Pain[select name="variable_1" value="NO|YES"]
LOC[select name="variable_1" value="NO|YES"]
Alcoholic Beverages[select name="variable_1" value="NO|YES"] 
Recreational Drugs[select name="variable_1" value="NO|YES"] 
Pregnancy[select name="variable_1" value="NO|YES"] 
Foreign Travel[select name="variable_1" value="NO|YES"] 
Recent Illness[select name="variable_1" value="NO|YES"]
Recent Trauma[select name="variable_1" value="NO|YES"]
Recent Surgery[select name="variable_1" value="NO|YES"]

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==  Objective  ==
===================================================================================

ABC'S 

Airway: 
[checkbox name="variable_1" value="Patent|Compromised|Obstructed"]

Breathing: 
---Regularity
[checkbox name="variable_1" value="Regular|Irregular|Agonal|Apneic"]
---Rate
[checkbox name="variable_1" value="Normal|Fast|Slow"]
---Depth
[checkbox name="variable_1" value="Normal|Shallow|Deep"]
---Effort 
[checkbox name="variable_1" value="Without Effort|With Effort"]

Circulation:
Skin:
[checkbox name="variable_1" value="Pink|Pale|Cyanotic|Jaundice|Lividity|Mottled"]