Chronological Record of Medical Care

Miscellaneous Factors.

Chronological Record of Medical Care (Cont)

Public Health and Disease Concerns Related to Coast Guard Operations
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CHRONOLOGICAL RECORD OF MEDICAL CARE

HEALTH RECORD

DATE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

AMIO SCREENING OVERPRINT

Females:

not pregnant

SUBJECTIVE: _____ year old male / female (circle) with a _____ day history of:

dizziness / fainting spells

other symptoms ___________________

no symptoms

Other family members ill:

Recent travel:

Current medications:

OBJECTIVE:

General: well nourished, well hydrated

moderately ill appearing, mildly dehydrated

non-combative

combative

not alert / not oriented

alert & oriented

Other observations:

ASSESSMENT / PLAN:

Individual is stable, no medical intervention needed

Individual is not stable, medical attention required. Contact medical personnel for assistance.

Additional precautions:

_____________________________

SIGNATURE

RECORDS

PATIENT'S IDENTIFICATION (Use this space for

MAINTAINED

Mechanical Imprint)

AT:

PATIENT'S NAME ( Last, First, Middle initial )

SEX

RANK/GRADE

RELATIONSHIP TO SPONSOR:

STATUS

SPONSOR'S NAME

ORGANIZATION

DEPART./SERVICE

SSN/IDENTIFICATION NO.

DATE OF BIRTH

AMIO SCREENING OVERPRINT

CHRONOLOGICAL RECORD OF MEDICAL CARE

STANDARD FORM 600 (EF)

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