Title Page

  • Automatically Generated Document Number

  • Report Title

  • Recorded by

  • Date created

Medical Report Form


  • Casualty Name

  • Casualty Age

  • Casualty Date of Birth


  • Time of Injury/Incident


  • Mechanism of Injury/Onset of Illness


  • Injuries Found/Suspected Symptoms of Illness

S - Signs

  • Respiration Rate (breaths per minute)

  • Pulse Rate

  • SpO2 - Air

  • SpO2 - on O2

  • Blood Pressure - Syst

  • Blood Pressure - Diast

  • Pupil Diameter (mm) - left eye

  • Pupil Diameter (mm) - right eye

  • Blood Sugar - BM

  • Blood Temperature

  • Where is the casualty on the AVPU scale? Alert, Verbal, Pain, Unresponsive


  • Treatment Given



  • Allergies


  • Normal Medications


  • Previous Medical History


  • Last Oral Intake


  • Events leading to illness or injury

  • Filling out Vital Signs Monitor Chart? (inside medical folder)

  • Evacuation Required?

  • Fill out Medical Report for Evacuation (inside medical folder)

Patient Timeline Record

  • Following the initial assessment, please record daily patient treatment/progress below: (including all dates)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.