NAME

DoB

RACE NUMBER

RIDER/PASSENGER

CLASS

LOCATION

DATE

TIME

KNOCKED OUT?

YesNo

CASUALTY CONDITION

AlertVerbalPainUnresponsive

HAEMODYNAMIC
RADIAL PULSE PALPABLE?

YesNo

PULSE RATE PER MIN

BLOOD LOSS?

NoneSlightModerateSevere

RESPIRATORY RATE PER MIN?

SUSPECTED INJURIES

None ApparentHeadChestSpineLeft Upper ArmLeft ForearmRight Upper ArmRight ForearmLeft ThighLeft Lower LegRight ThighRight Lower Leg
OTHER INJURY

NOTES (including drugs)

DISPOSAL

HelicopterAmbulanceOwn Way Back

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