KARTU LUKA

NAMA : ..................................................................
JENIS KELAMIN : ..................................................................
USIA : ..................................................................
KELAS : ..................................................................

KEADAAN KORBAN

1) TINGKAT RESPON ( Awas Suara Nyeri Tidak Respon )

2) GANGGUAN PERNAPASAN ( Ya Tidak )
3) CEDERA YANG DIALAMI
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4) PERTOLONGAN PERTAMA YANG DILAKUKAN
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5) TANDA VITAL
Denyut Nadi : ..................................................................
Pernapasan : ..................................................................
Suhu Tubuh : ..................................................................
Tekanan Darah : ..................................................................
Kulit : ..................................................................
6) RIWAYAT PENDERITA
Keluhan Utama : ..................................................................
Obat-obatan : ..................................................................
Makanan/Minuman : ..................................................................
Penyakit : ..................................................................
Alergi : ..................................................................
Kejadian : ..................................................................

Pekalongan,

Penolong