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Wellington Caving Group

Victim Report

Version 1999 November   Corrections and updates to the webmaster -> mailto:wcg-webmaster [snail] caving [period] org [period] nz?subject=Victim%20Report%20form please NZSS Accident Victim Report (One sheet for each victim)

1. Name  
Gender   F / M
Next of Kin

(if known)

Medical Condition (Delete not applicable)
2. Head Has patient had a head injury? Yes / No / Don't know
  Is patient conscious? Yes / No
Has patient been UNconcious? Yes / No
Does the patient seem to be getting Better / Worse
Is / Was patient Dizzy / Seeing stars / Disoriented
Is / Was patient vomiting Yes / No
Is patient coughing up blood? Yes / No Bright / Dark / Frothy
Is any fluid coming from ears? Yes / No Colour
Is any fluid coming from nose? Yes / No Colour
What is colour of face? (was patient looked at
in carbide/electric light?)
What is colour of lips?  
3. Breathing Any trouble breathing? Yes / No 
4. Pain Is there any pain? Yes / No
5. Breaks or suspected breaks (include neck and spine)
Where?Any major deformity?Any loss of sensation?Any loss of movement?
6. Bleeding
Where?Graze / Cut?Length?Depth?Width?Profuse / Minor?
7. Other Pulse Rate  
  Can patient walk or move in any way? Yes / No
  Any known medical conditions?
(eg. diabetes, epilepsy, asthma)
Check for Medic-Alert
  When did the patient last eat? Drink?
  What is the risk of Hypothermia? Low / Medium / High Is the Patient Wet / Dry?
  How is the patient dressed?  
  What action has already been taken?
(eg. medication / comfort)
8. General Comments