Mass Casualty Patient Self-Assessment Form
This three-page illustrated handout is a self-assessment form that health care providers can give to patients to write down important information to expedite care in the event of a disaster or mass casualty event. It uses a question and answer format and checklist to identify who is filling out the form, the reason why they are there, if they are pregnant, and what health problems they are experiencing. The document includes an illustration of the human body where the patient can mark where they feel pain, as well as check boxes to indicate any diseases or conditions they have or had in the past, medicines they are taking, and allergies.
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The English language resource was created or reviewed by a medical professional for quality and accuracy.
A qualified translation company performed an independent review by a second translator, and a client advocate.