DCHART1

DISPATCH:
[textarea name= “default=""]

CHIEF COMPLAINT:
[textarea name="variable_2" default=""]
Secondary Complaints:[text name="5" size = 55 default=""]

HISTORY:
Medical History:
[textarea name="variable_6" default=""]
Allergies:
[checkbox name="variable_1" value="Unknown/ Unable to Obtain"] [text name="7" size = 55 default=""]
Medication:
[checkbox name="variable_1" value="Unknown, Unable to Obtain"] [text name="8" size = 55 default=""]
Events Leading Up to Injury/Illness:[text name="9" size = 55 default=""]
Onset of Illness/Injury:[text name="10" size = 55 default=""]

ASSESSMENT:
Mechanism of Injury/Illness
[text name="10" size = 55 default=""]
General Impression/Appearance of Patient
[text name="10" size = 55 default=""]
Airway:
[checkbox name="Airway" value="Open and Patent|Compromised|Manually Opened Airway|Requires Airway Management Device"][text name="10" size = 55 default=""]
Breathing:
[checkbox name="Breathing" value="Adequate Depth and Rate|Shallow Respiration|Deep Respirations|Slow Respirations|Fast Respirations|Apneic"]
Skin Color/Condition:
[checkbox name="1234321" value="Pink, Warm, and Dry|Pale|Cool|Diaphoretic|Flushed|Cyanotic|Jaundiced|Lividity"]Provocation: [text name="11" size = 55 default=""]
Quality of Pain: [text name="12" size = 55 default=""]
Radiation of Pain: [text name="13" size = 55 default=""]