mor STATE OF KUWAIT ‘up. 2001 MINISTRY OF HEALTH PATIENT REPORT FORM Ses Age Soe? DERE OF BS. soso casi ba a case Ba Wan os Coa fase T}CL1 Lola} (1) sec FT]: tons eve ete oe ‘Type of oaldent: ae “Mobile AtHosptal | Jel Att =o semen : ‘al —— ay ‘ranster ae I DO PST A Katee rept apa oy Ee rome Wal] el ect is coe Ed oro nay Aare Net Led HL | seein CE] “ype et ner weet me aa ett oa NS i eh oh ha ed connen “8 drown oooogu0g mae] CJrenale Se 0 + pe [Resesoment & Observation; —Firt iat Second Bio ommsy] FCM cua = CoEREa= 2 = sumer GOO [ooo | TTF, te Seeeigry OOOO) O-0.0.07R% Og, Oi Owe 0 te a ae fate) mite { IF eww Cl oarae sew fort tert Ce. at kame alr econ Appia eas yan COI| animes |] 0, sod Las pen es Tee eee Oxygen: 7 success C] um G]| sues coher vezmasa J nodesal I~ [_L_ jcoat | vimecensal | ee I a aes, a cee aorenaune om] OO O OO) aon oiaeeeiea T9079 902030) +020 30 «DJ atrorne ys ds a 4 4 f f ee: sere] Oe OD] vroomne GeHBeE ome aces (0:00-0:00) rove me OOO OO Boos Bresea omseay ore] OO OOO syste ] cweacon me CLO OOOU ae ET [ = |wsrerimeoue COOOOO [ noone ETE C) Caan Beer TOO Cho ores OOOOOG Seles on OT <0 swoon OOOO : Recon wxizuen omen [1 Se genvee ‘Conscious level: 4 oO Oo 4 4 oool Lppezegereneemnet o Glasgow Coma Scale: . 2 Ev Mm Signature: — an wpe CLT | scott goon eave ren LL] ‘foma) Geen easy §— CACO] 120s. (Geen 9) a7) (eae) :O.0/0.0 scandent signature Patient outcome on arrival at hopital 30-0700 vos} Eine respiaton Yes{_] [_]No conscious Yes] [no || Receiving Docto irevitton Yee] []No Pain stamp & signature:Sie ad pl isin nga pn Sep aims cain PERCENTAGE OF BURN ARES HOSPITAL CODES scenes copes HOSPITAL Sepa ‘Shik | 2 su | A ae = 3 > a = a = ‘Um-alheeman Soom | 7! Haire sie ieee aie ines [o z 2 ath as sips laine aNcrs Pon nyPONIA RANGES OF HYPOVOLEMIA nb ahese tb Bt stele ook at diane tp be esi a eames tp Normal range: 97-100% yet Unt mee | ‘Mita hypein| 10-96% a a en aedeeigynln: AIO staan nay ome wwe [sis Se Sees pp as an 8% Ooo a aa a 1h sugse [ate wee | uss | ried al peels 13a eatuseeomt eee Teri CONSCIOUS LEVEL CHECKS: acer? 2000 | 30-00 Taso] we . aint awake | :| AVPU Sate —— peeree|*| sas ste Rast oma oid EVEOPENNG RESTONGE [Poms] [0] ont ware | StLa | PACE | nema | aoageuc | = | Jiw_| jis ema [ae — : 7 bts a paar 3 1) Ses : = ers lofming ie : 2] Seceiea ~ | Nstye Response 1 i] Aes Z x a | pesTVERRAL RESONSE ns Sn [aS] Ee 4 a x fa $ é 36% x | em ; 3 a won | a w * 2% wa | : fas uo [x [eet x ‘TOTAL RESPONSES “conc ee Lcae"