CERT
Clinical Information Report
Incident Number
Date and Time
Building
Room
Client Information
Surname
Given Name
Date of Birth
Address
City
Province
Postal Code
Phone
Student/Banner ID
Clinical Information
Primary Complaint
Time
History of Event
Past Medical History
Cardiac
COPD
CVA/TIA
Asthma
Diabetes
Seizure
Medications
Age
Sex
-select sex-
Male
Female
Other
Weight (lbs)
Appearance
-select injury location-
Head/Neck
Chest
Back
Pelvis
Upper Extremities
Lower Extremities
N/A
Notes
