NAME

DoB

RACE NUMBER

RIDER/PASSENGER

CLASS

LOCATION

DATE

TIME

KNOCKED OUT?
 Yes No

CASUALTY CONDITION
 Alert Verbal Pain Unresponsive

HAEMODYNAMIC
RADIAL PULSE PALPABLE?
 Yes No

PULSE RATE PER MIN

BLOOD LOSS?
 None Slight Moderate Severe

RESPIRATORY RATE PER MIN?

SUSPECTED INJURIES
 None Apparent Head Chest Spine Left Upper Arm Left Forearm Right Upper Arm Right Forearm Left Thigh Left Lower Leg Right Thigh Right Lower Leg
OTHER INJURY

NOTES (including drugs)

DISPOSAL
 Helicopter Ambulance Own Way Back

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