1. LAST NAME, FIRST NAME / NOM ET PRENOM
RANK/GRADE
MALE / HOMME
FEMALE / FEMME
SSN / NUMERO MATRICULE
SPECIALTY CODE / GPM
RELIGION / RELIGION
2. UNIT / UNITE
FORCE / ELEMENT
NATIONALITY / NATIONALIT
A/T
AF/A
N/M
MC/M
BC / BC
NBC / NBC
DISEASE / MALADIE
PSYCH/PSYCH
3. INJURY / BLESSURE
AIRWAY / TRACHEE
HEAD / TETE
FRONT / DEVANT
BACK / ARRIERE
WOUND / BLESSURE
NECK/BACK INJURY /
BLESSURE AU COU/AU DOS
BURN / BRULURE
AMPUTATION / AMPUTATION
STRESS / TENSION
OTHER (Specify) / AUTRE (Specifier)
_______________________________
_______________________________
4. LEVEL OF CONCIOUSNESS / NIVEAU DE CONSCIENCE
ALERT / ALERTE
PAIN RESPONSE / REPONSE A LA DOULER
VERBAL RESPONSE / REPONSE VEBALE
UNRESPONSIVE / SANS REPONSE
5. PULSE / POULS
TIME / HEURE
6. TOURNIQUET / GARROT
TIME / HEURE
NO / NON
YES / OUI
7. MORPHINE / MORPHINE
DOSE / DOSE
TIME / HEURE
8. IV / IV
TIME / HEURE
NO / NON
YES / OUI
9. TREATMENT/OBSERVATIONS/CURRENT MEDICATIONS/ALLERGIES/NBC (ANTIDOTE)
TRAITEMENT/OBSERVATIONS/PRESENTE MEDICATION/ALLERGIES/ANTIDOTES
10. DISPOSITION /
TIME / HEURE
RETURNED TO DUTY / RETOUR A L'UNITE
DISPOSITION
EVACUATED / EVACUE
DECEASED / DECEDE
11. PROVIDER/UNIT / OFFICIER MEDICALE/UNITE
DATE/DATE (YYMMDD
DD FORM 1380
U.S. FIELD MEDICAL CARD
Check Your Answers on Next Page
IS0871
7-17
Previous Page
