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air ambulance patient assessment form

PRELIMINARY INFORMATION TO DECIDE THE RIGHT PLAN OF TRANSFER

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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 International

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