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Mark on these figures where you feel pain.












Mark any diseases or conditions you have or have had in the past.
Asthma
Diabetes
Heart disease
Hepatitis
High blood pressure
Immunosuppression from HIV, cancer or other reason
Stroke
Mark any medicines you are taking.
Heart medicines
Blood pressure medicines
Blood thinners such as Coumadin
Breathing medicines
Insulin
Other over the counter medicines such as antacids, laxatives or pain medicines
Mark any allergies you have.
Dairy products such as eggs or milk
Seafood
Dye or iodine
Aspirin
Penicillin
Morphine
Sulfa
Latex
Other ____________________

Mass Casualty Patient Self-Assessment Form. 7/2007. Content developed through a partnership of the Central Ohio Trauma System, the
Columbus Medical Association Foundation, Columbus Public Health, Franklin County Board of Health, Mount Carmel Health, Ohio State
University Medical Center and OhioHealth, Columbus, Ohio. Available for use as a public service without copyright restrictions at
www.healthinfotranslations.org.