background image
Please Complete This Form So We Can Help You
Keep this paper with you. A staff person will look at your paper soon.
Patient’s name ______________________________________________
Female
Male
Age _______
Weight _______ kilograms/pounds
Who is filling out this form?
Me, the patient
Patient’s family member or friend
An interpreter for the patient
Why are you here?
I am ill or injured because of a disaster
I am ill or injured but not because of a disaster
I am here to help or look for a family member
Are you pregnant?
Yes
I am in labor
No
I am not sure
What problem are you having? Mark all that apply.
I am having trouble breathing
I am having chest pain, pressure or discomfort
I am bleeding
I have a severe headache
I feel dizzy or lightheaded
I am having problems seeing
I cannot hear
I have a broken bone
My skin is burning
I have a skin rash, swelling or redness
I feel numbness or tingling
I have nausea, vomiting or diarrhea
I have a runny nose, cough or a fever