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air ambulance patient assessment form
PRELIMINARY INFORMATION TO DECIDE THE RIGHT PLAN OF TRANSFER
CALL US
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
Form provided by
Freedback
.
Air Ambulance International
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