Ministry of Health Emergency Chart

DATE: Hospital No:

Surname:
First Name:
Date of Birth: / / Age: Sex: M F
Address:
Telephone: (H) (M)
Contact Person: Relationship:
Presenting Complaint / Duration: Time:

Pain Level:
'Ikai ha langa 'Ikai matu'uaki 'e langa

Triage Observations Triage Assessment

Temp: C 1 1mm1111t1l1
Pulse: / min
1 w1t11n 11 m1n
BP: mm Hg
RR: / min 1 w1t11n 11 m1n

Sp02: % (room air) 1 w1t11n 11 m1n

BSL: mmol/L
1 1 1 111 m1n
Weight: kg

Medical Conditions Smoking Status

Hypertension Never smoked
Diabetes Mellitus Ex-smoker (for _________ d/w/m/y)
Heart condition Current smoker
Asthma
Other:
Nurse Signature:

Diagnosis:
Notifiable Disease No.