Emergency Care Forms

EMERGENCY CARE AND TREATMENT ADMISSION FORM
PERSONAL INFO
NAME
TRANSPORTATION TO HOSPITAL
X
Amber Elizabeth Julian - P1

DATE OF BIRTH
7/14/2004
GENDER
PRIVATE VEHICLE
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
Female
CHIEF COMPLAINT(S)
ARRIVAL
VITALS
DATE
TIME
5/14/2009
9:15AM
9:30am
BP
80/40
PULSE
110
TIME SEEN BY PROVIDER
RESP.
30
9:45AM
TEMP.
98.6
WEIGHT
(Include symptom(s), duration)
Patient is having trouble breathing and complains of bouts of dizziness. Symptoms began while the young girl was
playing in her back yard.
CURRENT MEDS
TIME
HEIGHT
CATEGORY
EMERGENT
URGENT
(Tetanus immunization and other data)
All childhood vaccinations are up to date.
NON-URGENT
DESCRIBE
(1) Pertinent History; (2) Examination - Include results of tests and X-Rays; (3) Diagnosis; (4) Treatment/Procedures Include medication given and follow-up
(1) Patient is an apparently healthy 4-year-old girl. There is no personal history of allergies, although the father is allergic to seafood as well as pet dander. The
mother reported that she may have lost consciousness during the drive to the hospital, but she could not be sure.
(2) Upon examination, patient had low blood pressure, high respiratory rate, and mild swelling of the respiratory tract.
(3)
(4)
OFFICIAL MEDICAL RECORD COPY
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PERSONAL INFO
NAME
X
PRIVATE VEHICLE
Jim Russell - P2
AMBULANCE
DATE OF BIRTH
MED-EVAC
3/4/1979
GENDER
OTHER (DESCRIBE)
VITALS
TIME
2/23/2009
Male
CHIEF COMPLAINT(S)
ARRIVAL
DATE
10:00PM
TIME
12:22a
1:25a
BP
135/85
140/80
92
PULSE
90
RESP.
15
16
12:20AM
TEMP.
100.1
101.7
WEIGHT
Patient complains of a severe toothache and persistent fever. He had root canal surgery a week ago.
190
HEIGHT
6' 0"
CATEGORY
EMERGENT
CURRENT MEDS
URGENT
Ibuprofen (600mg every 4 hours) for pain; Acetominophen for fever
NON-URGENT
DESCRIBE
(1) Patient has a history of low blood pressure. All previous cardiac workups were normal, although the patient now notes occasional heart palpitations or skipped
beats. Root canal surgery was completed with no complications. The pain subsided three days after the procedure and the patient returned to work as a teacher.
The pain has returned over the last two days. Because it was after hours, the patient was told to come to the emergency room.
(2) Notable swelling is appreciated around the left lateral incisor. Small amount of pus is visible. Patient presents with a fever and has been experiencing night
sweats. Patient has been unable to eat due to high sensitivity in the area.
(3)
(4)

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PERSONAL INFO
NAME
David Argula - P3
DATE OF BIRTH
1/4/2009
GENDER
X
PRIVATE VEHICLE
AMBULANCE
OTHER (DESCRIBE)
CHIEF COMPLAINT(S)
VITALS
TIME
TIME
2:30p
3:09p
BP
65/30
55/30
PULSE
100
135
RESP.
27
25
3:00PM
TEMP.
99.1
99.4
WEIGHT
22lbs
HEIGHT
12/27/2009
MED-EVAC
Male
ARRIVAL
DATE
2:06pm
Parents of the child found a half-empty bottle of baby aspirin in their suitcase. The baby is thought to have consumed
the pills, but they can not be sure of how many.
CURRENT MEDS
28in
CATEGORY
EMERGENT
URGENT
All vaccinations are up to date
NON-URGENT
DESCRIBE
(1) The baby was born 6 weeks premature, but has had no complications. The family is on vacation in the area. The mother made sure to pack medications for all
members of her family. The baby apparently climbed out of the portable crib during naptime and somehow reached an open bottle of baby aspirin (father takes
one each day for his heart). The parents do not remember how many pills were left in the bottle, but they are sure some are missing.
(2) Patient is quiet and breathing is shallow. Quick pulse changes are noted. The patient is drooling and has occasional tremors or convulsions.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
Priya Ghosh - P4
DATE OF BIRTH
12/20/1984
GENDER
AMBULANCE
OTHER (DESCRIBE)
CHIEF COMPLAINT(S)
VITALS
TIME
6/17/2009
MED-EVAC
Female
ARRIVAL
DATE
7:32am
7:05am
7:25a
BP
122/80
120/75
85
PULSE
80
RESP.
15
16
7:55AM
TEMP.
98.2
98.4
WEIGHT
145
HEIGHT
Patient was hit by a car while bicycling to work. On the scene, the patient complained she had trouble moving her legs
and could not twist at the waist.
CURRENT MEDS
TIME
5'7''
CATEGORY
EMERGENT
URGENT
Tetanus last month upon employment at new job; Lipitor
NON-URGENT
DESCRIBE
(1) The patient is generally healthy with a family history of hypercholesterolemia. Patient reports she often forgets to take her medication. She is currently training
for a triathlon and is in excellent physical condition.
(2) On the scene, the patient was alert and talking. She is lucid when she arrives in the ER. She has various cuts and contusions on her face and right arm, but
blood loss is minimal. Examination reveals no visible broken bones, but her pelvis is extremely tender. Patient has limited range of motion from the hip joints.
Patient is sent for diagnostic scans.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
Michael Helms - P5
AMBULANCE
DATE OF BIRTH
10/10/1971
GENDER
Male
CHIEF COMPLAINT(S)
MED-EVAC
X
OTHER (DESCRIBE)
Squad car
ARRIVAL
VITALS
DATE
TIME
8/13/2009
8:45pm
9:10p
BP
140/87
PULSE
79
RESP.
19
9:25PM
TEMP.
98.1
WEIGHT
Patient was shot in the left shoulder while chasing a suspected robber. There does not appear to be an exit wound.
Patient complains of tingling in the arm.
CURRENT MEDS
TIME
HEIGHT
CATEGORY
EMERGENT
URGENT
Coumadin; Zyban; last tetanus shot was over ten years ago
NON-URGENT
DESCRIBE
(1) Patient is a police officer with a history of deep vein thrombosis (DVT) who currently takes Coumadin. The patient is a self-reported one pack a day smoker,
although he has been trying to quit.
(2) On the scene, the patient continued pursuit of the suspect for twenty minutes after injury occurred. The bullet appears to have missed the major blood
vessels, but blood loss is significant. Patient begins to shift in and out of consciousness upon arrival. An exit wound cannot be located, so the bullet is suspected
to remain in the body. The patient now reports tingling in the arm.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
Doris Dingman - P6
DATE OF BIRTH
5/5/1937
GENDER
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
ARRIVAL
VITALS
DATE
TIME
7/24/2009
8:34am
Female
CHIEF COMPLAINT(S)
TIME
8:05a
BP
140/85
PULSE
85
RESP.
18
TEMP.
98.2
WEIGHT
108
Patient slipped getting out of the shower. She is unable to put pressure on her right leg and complains of wrist pain.
HEIGHT
5' 2"
CATEGORY
EMERGENT
CURRENT MEDS
URGENT
Lopressor; oral estrogen
NON-URGENT
DESCRIBE
(1) Patient is a 72-year-old woman with a history of high blood pressure. She has recently been unsteady and has broken four bones in the past two months two
of these breaks were from minor home accidents. The patient noted that she has not been cooking much for herself since her husband died two years ago and
relies on frozen meals.
(2) Patient called 911 from her home. Her right wrist and right ankle are extremely swollen and discolored. The patient can put little to no weight on the right leg.
Blood pressure, heart rate, and respiration appear to be stable.
(3)
(4)

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PERSONAL INFO
NAME
Drea Nunzio - P7
DATE OF BIRTH
3/28/2002
GENDER
X
PRIVATE VEHICLE
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
Female
CHIEF COMPLAINT(S)
ARRIVAL
VITALS
DATE
TIME
9/23/2009
4:45pm
TIME
5:30p
BP
100/60
PULSE
85
RESP.
15
6:35PM
TEMP.
99.5
WEIGHT
Patient has been vomiting for the past two days and has been unable to hold down any food/fluids.
HEIGHT
CATEGORY
EMERGENT
CURRENT MEDS
URGENT
All vaccinations are up to date; just finished cycle of amoxicillin
NON-URGENT
DESCRIBE
(1) Patient is a 7-year-old girl with a history of otitis media and chronic bronchitis. Vomiting began late in the evening after the patient returned from a soccer
party. The patients father suffers from Crohns disease.
(2) Patient is extremely lethargic and complains of a headache. Vomiting continues in the ER accompanied by stomach pains. The patient and her family eat the
same foods at home and no one else in the family is sick.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
J.D. Thomas - P8
DATE OF BIRTH
1/2/1992
GENDER
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
Male
CHIEF COMPLAINT(S)
ARRIVAL
VITALS
DATE
TIME
10/2/2009
7:35PM
TIME
7:15p
BP
110/78
PULSE
88
RESP.
17
8:15AM
TEMP.
97.6
WEIGHT
Patient passed out during a football game after a hard hit. He was extremely disoriented and was escorted off the field.
HEIGHT
CATEGORY
EMERGENT
CURRENT MEDS
URGENT
None; NKDA
NON-URGENT
DESCRIBE
(1) Patient has no medical history of syncope or neurological deficit. He has not missed a day of school in over 7 years. 20 minutes after the incident on the field,
the patient appeared lucid. However, he has no recollection of what happened and why he is no longer at the game.
(2) Upon examination, the patient appears alert, but has trouble maintaining balance. He reports a slight ringing in his ears. After a few hours, his speech began
to slur.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
Stacey Reeves - P9
DATE OF BIRTH
11/24/1976
GENDER
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
Female
CHIEF COMPLAINT(S)
ARRIVAL
VITALS
DATE
TIME
6/1/2009
10:00am
TIME
10:10a
BP
90/60
PULSE
78
RESP.
15
10:15AM
TEMP.
97.8
WEIGHT
Patient presents with severe lacerations on the distal phalanges of the right hand. Injury occurred at 9:05AM.
HEIGHT
CATEGORY
EMERGENT
CURRENT MEDS
URGENT
Atripla; Vitamin B12 supplements; multivitamin; tetanus shot 1/15/2009
NON-URGENT
DESCRIBE
(1) Patient was attempting to remove material from the blades of a lawnmower when the power shifted on. She was able to remove her hand quickly, but there is
severe damage to the fingers. Patient has been HIV positive since 2004. Her T-cell count had always stayed within normal limits. Her husband called 911 and
attempted to stop the bleeding using pieces of rope.
(2) There are severe lacerations on the 2nd and 3rd finger. An open fracture is visible, but further imaging is required to determine if there are additional breaks.
Since the patient was able to cut off blood flow to the injured area, blood loss was halted, but is still significant. The patient is pale and clammy and reports pain
of 7 on a scale of 1-10.
(3)
(4)

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PERSONAL INFO
NAME
Sela Montogomery - P10
DATE OF BIRTH
4/12/1983
GENDER
X
PRIVATE VEHICLE
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
Female
CHIEF COMPLAINT(S)
ARRIVAL
VITALS
DATE
TIME
6/6/2009
12:15pm
3:15p
BP
100/69
PULSE
67
RESP.
16
3:30PM
TEMP.
98.5
WEIGHT
Patient complains of visual and auditory hallucinations and difficulty concentrating. Symptoms have been on and off for
the past three months.
CURRENT MEDS
TIME
HEIGHT
CATEGORY
EMERGENT
URGENT
Paxil; occasional OTC sleeping pills
NON-URGENT
DESCRIBE
(1) The patient suffered bouts of depression throughout high school but was treated with a combination of medication and psychotherapy. She has been feeling
tired lately, but she cant seem to fall asleep at night. A coworker found the patient wandering the streets outside of the office and brought her in. The patient
lives with a roommate who has been called.
(2) The patient could not focus during the examination and her speech was disorganized. The patient alternated between a flat affect and unpredictable
emotional responses. When lucid, the patient reports hearing voices that become worse when she is alone. Blood pressure, respiration, and heart rate were all
normal. The patient does not have a fever.
(3)
(4)

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PERSONAL INFO
NAME
Maria Flores - P11
DATE OF BIRTH
4/1/1979
GENDER
X
PRIVATE VEHICLE
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
Female
CHIEF COMPLAINT(S)
ARRIVAL
VITALS
DATE
TIME
9/12/2009
6:45AM
7:10a
BP
150/90
PULSE
98
RESP.
20
7:10AM
TEMP.
98.9
WEIGHT
165
The patient, 28 weeks pregnant, is experiencing regular contractions and pain in the abdomen. Pain started at 3AM first attributed to heartburn and gas.
CURRENT MEDS
TIME
HEIGHT
5'5"
CATEGORY
EMERGENT
URGENT
Prenatal vitamin; iron supplements
NON-URGENT
DESCRIBE
(1) The patient is a 30-year-old woman. This is her first clinical pregnancy. She has a history of miscarriage and elevated blood pressure. The patient was recently
diagnosed with gestational diabetes. Not wanting to go on medication, she has been trying to control her blood sugar with diet and exercise.
(2) The patient is experiencing regular, mild contractions every 10-12 minutes and a low, dull backache. Blood pressure is elevated. The amniotic sac is still intact.
Fetal heartrate appreciated by Doppler ultrasound - 138bpm.
(3)
(4)

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PERSONAL INFO
NAME
X
PRIVATE VEHICLE
Jon James - P12
AMBULANCE
DATE OF BIRTH
MED-EVAC
7/10/1951
GENDER
OTHER (DESCRIBE)
ARRIVAL
TIME
9/17/2009
6:30PM
Male
CHIEF COMPLAINT(S)
VITALS
DATE
TIME
7:16p
BP
100/75
PULSE
80
RESP.
17
TEMP.
98.9
WEIGHT
Patient presented with burns on both hands and moderate pain.
HEIGHT
CATEGORY
EMERGENT
CURRENT MEDS
URGENT
Vicodin; daily baby aspirin; multivitamin
NON-URGENT
DESCRIBE
(1) The patient is a 56-year-old man who lives alone. Attempting to answer the phone and flip hamburgers, he accidentally moved the pan from the gas and
ignited his sweatshirt. Upon reflex he used his hands to pat out the fire, sustaining burns on both hands. The patient admits to popping two vicodin he had left
from dental surgery before calling a friend to take him to the hospital.
(2) Examination reveals an area of 3rd degree burn on the left hand. The second and fourth finger are charred and the flesh appears waxy. Large blisters cover
the skin and ooze a clear fluid. The patient reports little to no pain at the moment.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
Kayleigh Dubois - P13
AMBULANCE
DATE OF BIRTH
3/23/1991
GENDER
Female
CHIEF COMPLAINT(S)
MED-EVAC
X
OTHER (DESCRIBE)
Walked
ARRIVAL
VITALS
DATE
TIME
9/15/2009
4:14pm
TIME
6:45p
BP
90/60
PULSE
65
RESP.
16
7:00PM
TEMP.
99.6
WEIGHT
Patient complains of abnormal fatigue and has recently noted a palpable lump on the side of her neck.
HEIGHT
CATEGORY
EMERGENT
CURRENT MEDS
URGENT
None
NON-URGENT
DESCRIBE
(1) The patient is an 18-year-old college freshman. Patient was diagnosed with Hodgkin's lymphoma at age 7. After two rounds of chemotherapy, she was
deemed cancer-free and has been in remission for the past 10 years. The patient reports periodic night sweats and a weight loss of about 5 pounds. She
attributes her weight loss to crappy dorm food.
(2) The lymph nodes in the neck are swollen and the patient has a low grade fever.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
George Hampton - P14

DATE OF BIRTH
1/30/1953
GENDER
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
ARRIVAL
VITALS
DATE
TIME
5/24/2009
8:18am
Male
CHIEF COMPLAINT(S)
8:00a
BP
160/97
PULSE
88
RESP.
19
TEMP.
98.6
WEIGHT
Patient is experiencing numbness in his left arm and a sudden onset headache. This morning the patient began having
trouble speaking.
CURRENT MEDS
TIME
HEIGHT
CATEGORY
EMERGENT
URGENT
Caduet; Glucotrol; aspirin
NON-URGENT
DESCRIBE
(1) The 46 year-old patient, a type II diabetic, has a family history of heart disease. His mother died of a heart attack at age 49 and his brother recently had triple
bypass surgery. Four months ago, the patient was treated for minor transient ischemic attacks (TIAs) and was sent home on blood thinners.
(2) The patient is having trouble finding the words to explain what is happening to him. When asked to raise his arms over his head, the patient is unable to keep
the right arm in the air.
(3)
(4)

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PERSONAL INFO
NAME
Michael Billups - P15
DATE OF BIRTH
11/11/1994
GENDER
X
PRIVATE VEHICLE
AMBULANCE
MED-EVAC
OTHER (DESCRIBE)
Male
CHIEF COMPLAINT(S)
ARRIVAL
VITALS
DATE
TIME
8/7/2009
11:14am
12:55p
BP
100/74
PULSE
93
RESP.
21
1:25PM
TEMP.
99.2
WEIGHT
Patient presents with severe abdominal pain that has lasted for the past 24 hours. The patient notes some pain in the
joints of the leg.
CURRENT MEDS
TIME
HEIGHT
CATEGORY
EMERGENT
URGENT
Folic acid, Exjade; Motrin
NON-URGENT
DESCRIBE
(1)The 15 year-old patient has sickle cell disease. Patient has had numerous blood transfusions over the past ten years the last of which was 4 months ago. Two
weeks ago, he was prescribed antibiotics for a urinary tract infection, but only took for 7 of the 10 days specified.
(2) Skin is pale and shows the beginnings of jaundice. Both heart rate and respiratory rate are slightly elevated. The stomach is extremely tender to the touch and
the spleen appears enlarged.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
Hailey Simko - P16

DATE OF BIRTH
8/18/1967
GENDER
AMBULANCE
X
OTHER (DESCRIBE)
CHIEF COMPLAINT(S)
VITALS
TIME
5:30p
6:00p
6:30p
100/78
96/50
86/50
PULSE
99
70
50
RESP.
17
15
12
7:35PM
TEMP.
98.1
97.6
97.1
9/29/2009
MED-EVAC
Female
ARRIVAL
DATE
7:34pm
BP
WEIGHT
Patient was pinned in car following a motor vehicle accident. A piece of metal from the car is still lodged in the patient's
chest. Patient is having trouble breathing.
CURRENT MEDS
TIME
HEIGHT
CATEGORY
EMERGENT
URGENT
None; Latex allergy
NON-URGENT
DESCRIBE
(1) Rescue crews were able to extract the patient, but after 2 hours of work. EMS on the scene worked to stabilize the patient while she was still in the car. Patient
received oxygen by mask and fluids via a central line. Pressure bandages were placed on the chest. Patient has no significant medical history, but does have a
severe latex allergy as reported by a medical alert bracelet.
(2) Breathing is shallow and pulse is thready. Patient is unconscious when she reaches the ER. She has been shocked twice by a defibrillator in the helicopter, but
she is currently stable. Blood loss is significant. Metal shards remain lodged in her chest and left thigh.
(3)
(4)

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PERSONAL INFO
NAME
PRIVATE VEHICLE
ARRIVAL
DATE
VITALS
TIME
AMBULANCE
DATE OF BIRTH
TIME
BP
MED-EVAC
PULSE
OTHER (DESCRIBE)
GENDER
RESP.
TEMP.
CHIEF COMPLAINT(S)
WEIGHT
HEIGHT
CATEGORY
EMERGENT
CURRENT MEDS
URGENT
NON-URGENT
DESCRIBE

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EMERGENCY CARE AND TREATMENT ADMISSION FORM

Amber Elizabeth Julian - P1

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

All childhood vaccinations are up to date.

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

Ibuprofen (600mg every 4 hours) for pain; Acetominophen for fever

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

All vaccinations are up to date

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

Tetanus last month upon employment at new job; Lipitor

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

Lopressor; oral estrogen

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

All vaccinations are up to date; just finished cycle of amoxicillin

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER

(Include symptom(s), duration)

(Tetanus immunization and other data)

Atripla; Vitamin B12 supplements; multivitamin; tetanus shot 1/15/2009

OFFICIAL MEDICAL RECORD COPY

Project Lead The Way, Inc.

EMERGENCY CARE AND TREATMENT ADMISSION FORM

TIME SEEN BY PROVIDER