# PRE-HOSPITAL CARE FORM

Form 1x.2025 - Emergency Medical Services

Basic Information
Date
Departure Time
Arrival Time
Vehicle Used
Ambulance
Fire Truck
Others
Arrival at Scene - Location
Arrival at Scene - Time
Departure from Scene - Location
Departure from Scene - Time
Arrival at Hospital - Name
Arrival at Hospital - Time
Departure from Hospital - Location
Departure from Hospital - Time
Arrival at Station
Driver
Persons Present Upon Arrival
Police
Barangay Officials
Relatives
Bystanders
None
Patient Information
Patient Name
Date of Birth
Age
Gender
Male
Female
Civil Status
Single
Married
Address
Zone
Occupation
Place of Incident
Zone/Landmark
Time of Incident
Informant Details
Informant Name
Informant Address
Walk In / Call
Walk In
Call
Call/Arrival Time
Contact Number
Relationship to Victim
Personal Belongings
Hold Ctrl/Cmd to select multiple items
Other Belongings (specify)
Type of Emergency Call
Medical
Trauma
OB
General
Care Management
Immobilization
CPR
Bandaging
Wound Care
C-Collar
AED
KED
O² (LPM via)
Others
Initial Vital Signs
Time
Blood Pressure
Temp (°C)
Pulse (BPM)
Resp. Rate
Pain Score (0-10)
SPO2 %
Spinal Injury
Yes
No
Level of Consciousness
Alert
Verbal
Pain
Unconscious
Helmet Status
+ AB
No Helmet
Follow-up Vital Signs
Time
Blood Pressure
Temp (°C)
Pulse (BPM)
Resp. Rate
Pain Score (0-10)
SPO2 %
Spinal Injury
Yes
No
Level of Consciousness
Alert
Verbal
Pain
Unconscious
Chief Complaints
Chest Pain
Headache
Blurred Vision
Difficulty Breathing
Dizziness
Body Malaise
Other Complaints

###### Interactive Injury Mapping

Click on body diagram to mark injuries
FRONT VIEW
BACK VIEW

###### FOR Stroke Victim - F.A.S.T. Assessment

Face Drooping
(+)
(++)
Arm Weakness
(+)
(++)
Speech Difficulty
(+)
(++)
Time to Call
(+)
(++)
S.A.M.P.L.E.

###### FOR OB Patients Only

Baby Status
Delivery Time
Placenta
In
Out
LMP
AOG
EDC
Team Leader Notes
Team Information
Team Leader
Data Recorder
Logistic
1st Aider
2nd Aider
Hospital Endorsement
Endorsement
Hospital Name
Received by (Signature)

Signature over printed name

Date & Time

###### WAIVER - REFUSAL OF TREATMENT/TRANSPORTATION

I, the undersigned have been advised that assistance on my behalf is necessary and refusal of assistance and/or transportation for further treatment may result in death or impair my health condition. Nevertheless, I refuse to accept treatment and/or transport and assume all risks and consequences of my decision and release the Rescue 118 responders from any liability arising from any delay or refusal.

Patient Name & Signature

Patient signature

Witness Name & Signature

Witness signature

##### Ready to Submit

Review all information before submitting. Navigate back using tabs to check previous sections.

##### Select Ambulance

Please select an ambulance from the list below:

##### Select Fire Truck Type

Please select a fire truck type:

Penetrator
Specialized for rescue operations and penetration
Tanker
Equipped with large water tank for fire suppression