Medical Emergency Form
Serial No
Date
Name
Employee ID			Sex			Age
Department			Division			Mobile No
Supervisor				Supervisor Contact No
In Time at OHC or Call Received time:				Name of OHC Personnel attending the emergency
Caller Name				Out Time of Patient
Chief Complaints:
General Examination:
Pulse Rate		BP		SpO2		RBS
Systemic Examination:
Is the Patient taking any Medications - Give Details:
History of Drug Alleries:
Diagnosis:
Patient Admitted in Hospital: Yes/ No (If yes give details of hospital and time at which reached the hospital)
Ambulance Used: Yes/No
Treatment Given at Hospital:
Patient Discharged From Hospital: Yes/ No (If Yes provide date & Time)
Advice given on Discharge:
Did Patient return to work?: Yes/ No (if yes provide date & Time)