FORM LAPORAN PERTOLONGAN PERTAMA

Team Penolong : …............................................................................................

Identitas Korban
a. Nama : …............................................................................................
b. Umur : …............................................................................................
c. Jenis Kelamin :L/P
Kesan Umum : …............................................................................................

PENILAIAN DINI
Awas
Suara
Respon Korban
Nyeri
Tidak Respon

Napas : Kuat / Lemah / Tidak ada (Frekuensi : …..................... X / Menit )

Nadi : Kuat / Lemah / Tidak ada (Frekuensi : …..................... X / Menit )
Tekanan Darah :….....................................mmHg
Suhu :…......................................0C

JENIS CEDERA :
a. ….........................................................................
b. ….........................................................................
c. ….........................................................................
d. ….........................................................................

RIWAYAT PENDERITA
a. Keluhan : …..........................................
b. Obat : …..........................................
c. Makanan/Minuman : …..........................................
d. Penyakit : …..........................................
e. Alergi : …..........................................
f. Kejadian : …..........................................

TANDA VITAL
Jam Napas Nadi Tekanan Darah Suhu Kulit Keterangan
( x / menit ) ( x / menit ) ( mmHg) 0C

PENJELASAN TINDAKAN

Denpasar, …..................................
Ketua Team Penolong

…....................................................