1
Patient Intake
2
Vitals & Triage
B. Mode of Arrival
Select mode of Arrival
Walk-in
Self-presented patient
EMS
Ambulance handoff
Transfer
Outside facility
Law enforcement
Officer accompanied
C. Arrival / Patient Details
Walk-in
Last name
First name
Middle name
Sex
Male
Female
Date of birth
ID type
Driver`s license
Passport
National ID
ID number
Chief complaint
Emergency contact
Arrival notes
EMS
Last name
First name
Middle name
Sex
Male
Female
Date of birth
ID type
Driver`s license
Passport
National ID
ID number
Chief complaint
Agency name
Unit number
Incident number
Expected arrival time
Prehospital blood pressure
Pulse
Respiratory rate
Oxygen saturation (SpO2)
Temperature
Transfer
Last name
First name
Middle name
Sex
Male
Female
Date of birth
ID type
Driver`s license
Passport
National ID
ID number
Chief complaint
Sending facility
Sending provider
Provider phone
Transfer accepted by
Law enforcement
Last name
First name
Middle name
Sex
Male
Female
Date of birth
ID type
Driver`s license
Passport
National ID
ID number
Chief complaint
Agency name
Officer name
Badge number
Case number
