CAD Screening form ver 0.0.1 BETA

*Do you need an Ambulance or a Wheelchair van?

Ambulance Wheelchair (W/C)

*What is the patient's point of origin? (P/U Address)

Hospital Facility Airport Private Residence

Unit/RM#/Bed (optional):

*What is the patient's destination? (D/O Address)

Hospital Facility Airport Private Residence

Unit/RM#/Bed (optional):

*What is the patient's name?:

First

Last

*What is the patient's chief complaint/diagnosis?:

*Does this patient require Oxygen?

Yes No

*Does this patient require 4 or 12 lead EKG monitoring during transport?

Yes No

        *Does this patient require any IV fluids or medications to run during transport?
      

Yes No

*Is this patient intubated and/or on a ventilator?

Yes No

What is the patient's approximate weight?

lbs: KG:

*Is this a true bariatric patient? (350+ lbs OR cannot safely fit the standard 33in width of a railed stretcher OR requires additional personnel for safety)

Yes No

Any special precautions? (select all that apply)

Contact Precautions Droplet Precautions Airborne Precautions

*Barriers to residence (Stairs, steep incline, narrow halls, lift assist needed at Dest, dirt roads, etc)

Yes No

Additional comments

Additional comments:

Summary:

CAD Screening Form ver 0.0.1 BETA

This is a BETA, which means this version is just a prototype. Features, additional questions, warnings, and appearance can all still be modified and some features may not always function correctly!