PATIENT ASSESSMENT FORM

AIR AMBULANCE PATIENT ASSESSMENT FORM

Name of Patient
Age of Patient
Hospital of Origin
Hospital of Destination
Primary Contact Person/Relative/Company representative
Contact Address and Telephone no
Primary Diagnosis
Medical History
Current Clinical condition
Past Medical History
General condition/Height/Weight
Respiratory Assessment Done	Yes No
Self Ventilating	Yes No
Face Mask	Yes No
Nasal prongs	Yes No
BIPAP/CPAP	Yes No
ET Tube	Yes No
Tracheostomy	Yes No
Non Invasive Ventilation	Yes No
Invasive Ventilation	Yes No
Ventilatory settings	CMV SIMV Pressure support Volume control Bi level
Ventilator settings- Tidal volume/Rate/PEEP/FiO2/Respiratory rate/Suction needed or not.
ABG Findings
CARDIOVASCULAR ASSESSMENT DONE	Yes No
Pulse/Heart Rate
Blood Pressure
Rhythm
Temperature
Pacemaker	Yes No
ECG Findings
Inotropes support	Yes No
Anti arrhythmic needed	Yes No
IABP	Yes No
CVP
Cardiac output
NEUROVASCULAR ASSESSMENT DONE	Yes No
Consciousness	Conscious Alert Confused Semi conscious Sedated Paralysed Unconscious Comatose
Glasgow coma scale
Neurological defecit
RENAL ASSESSMENT DONE	Yes No
Indwelling cathetor	Yes No
Suprapubic cathetor	Yes No
Intermittent Catheterisation	Yes No
Dialysis	Yes No
Urine output
GASTRO INTESTINAL CHECK DONE	Yes No
Eating	Yes No
Drinking	Yes No
Nasogastric tube	Yes No
Parenteral (TPN)	Yes No
Lines	Peripherial Line Arterial Line CVP Line Pulmonary artery catheter Central line Others
Current Important Blood Investigations
Current Important Xray/CT/MRI scan Investigations
Current Medications
Additional Information you wish to convey to Us.
TRAVEL RELATED ASSESSMENT BY PHYSICIAN	Yes No
Prognosis for the Flight	Good Guarded Poor
Contagious and Communicable disease	Yes No
Physical and Psychological condition cause distress to other passengers during travel	Yes No
Can patient sit on a wheelchair	No Yes - during the complete journey Yes- period of 8 hours Yes- period of 4 hours Yes- period of 2 hours Yes - period of 1 hour Yes - short duration only
Can patient take care of own needs - Food/Toilet	Yes No
Type of Medical escort proposed by you	Doctor Nurse Doctor& Nurse
Does the patient need Oxygen during travel	No Yes - 2 lt/min Yes - 4 lt/min Higher amounts Ventilatory support
Does the patient need special medical equipments during travel	Monitor Pulse oximeter Ventilator Suction Nebuliser Pacemaker Incubator Others
Does the patient need hospitalisation at the destination	Yes No
Does the patient need an Ambulance to travel to the airport of origin and airport of destination	Yes No
Any other information you wish to provide for the smooth and safe transport of the patient
Can you provide a Medical report/Treatment summary for the patient	Yes No
Can you a Fitness to Fly Certificate for the patient	Yes No
Name of Doctor
Contact tel no
Email address
Designation/Hospital
Date/Time

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AIR AMBULANCE PATIENT ASSESSMENT FORM

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