11-01-10 Eligibility Period i 1 -30^-10 _Through_
Case IDg i 2 3 1 2 2 Number:
756J61
CASTILLO, FELIX
66U W WELLINGTON AVE BSMT
CHICAGO, IL
ONLY THE FOLLOWING PERSONS ARE ELIGIBLE:
FELIX CASTILLO ID#:15 1202900 DOB:ll-22-29
MEDICAL
*******************************************************
TOTAL NUMBER OF ELIGIBLE PERSONS: 1
00094396
•.^3^V./:-
-Please see front of card for important information-
AMBULANCE
Dispatch 312-949-9500 Admin. 312-949-9595
Fax 312;949-9292
1.
PATIENT CARE REPORT
Trip #o( q q Date: _L_/1£L/Ji_ [Ml dH [
SCT
PATIENT INFORMATION:
Name
^•frfrVvlte (Fire,) FiAit
(Ml)
Home Address
City
State
. ,Room*/Apt. No.
3a
^TLirt safari
st PHONE: ( 2nd PHONE: (
)
REASON FOR AMBULANCE TRANSPORT:
¦UP LOCATION
3Hi
UNIT #:
IE
LICENSE #
PICK-UP UOCATIQN WITH RM ,
. LEVEL OF RESPONSE: Xl Scheduled ? Stand-By
[^Non-Scheduled ? Personnel Return ? Immediate Response ? Cancelled/Refused Call
¦ ? Communicable
Disease - ? Emphysema
Dementia ? COPD___
HISTORY:
? Cardiac :_
Hypertension
? Glaucoma
? Asthma "H Diabetic
? denies .? Other_
History Obtained From: rjFI. ? Family^Other
Last.Orat Intake:-:-
? CVA w/deticits ¦ (Y/N)_
? Cancer _
"f^ Renal Failure
? Seizure
? Syncope _DUTI
? Amputation ot
MENTAL/BEHAVIOR
QAIert x.
? Confused
? Lethargic
• ? Unresponsive
? Cooperative
? Combative
? Unpredictable
? Disruptive
? Restraints—Type
1 2
_3
? Elopement Risk 4. \rj Language Barrier 5.
6.
LUNG SOUNDS
L R
¦QJ3 Clear
Current Isolation Precautions
_IT
? ? ? ? ? ?
?-Absent
? Coarse Rales
? Fine Rales
? Wheeze
? Rhonchi
? Diminished
PUPILS
L R
? ?
S-Q.
? ?
? ?
? ?
? ?
? ?
Meds:
MA
? None
? Ukri
P.E.R.L. Pinpoint Midrange Dilated Responsive Unresponsive
SKIN COLOR
1. ^Q Normal
2. ? Pale
3. ? Flush
4. ? Cyanotic
SKIN TEMP.
1. ""^] Normal
2. ? Hot
3. ? Cold
4. ?__
Weight _
lbs.
SKIN MOISTURE:
Normal
2. ? Moist 3. ? Dry 4. ? Diaphoretic
PHYSICAL ASSESSMENT
0 Deformity C Contusion A Abrasion P Penetration B Burn L Laceration S Swelling T Tenderness.
1 ...
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