Mass Casualty Patient Self-Assessment Form

Resource Properties

Abstract:

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.

Unless otherwise stated, users may print or download this health information resource from www.healthinfotranslations.org for personal, non-commercial use only. All images, logos, trademarks and all other applicable elements are copyright of their respective owners: the Ohio State University Wexner Medical Center, Mount Carmel Health System, OhioHealth, and Nationwide Children's Hospital.

Author(s):
Health Information Translations
Medical Review:
Yes
The English language resource was created or reviewed by a medical professional for quality and accuracy.
Development Method:
Resource developed in English and translated into other languages
Translation Review:
Company review
A qualified translation company performed an independent review by a second translator, and a client advocate.
Country:
N/A
Population:
N/A
Copyright:
In the Public Domain
Resource Last Reviewed by Author(s):
2/1/2013
Record Last Updated:
2/12/2018

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