In-flight First Aid Incident / Medical Report

In-Flight First Aid Incident / Medical Report
A/C Registration
Flight Number
Sector
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Time

Hour Minutes
Description of the Kit
Emergency Equipment Location
Kit Serial Number
Passenger Name
Age
Gender
Nationality
Passport Number
In-flight Illness Management

Select from below: Illness Management and Medicine Administered
Allergy
Bleeding
Burns
Cardiac Arrest
Childbirth / Delivery
Choking
Diarrhea
Difficulty of Breathing
Ear Problem
Eye Problem
Dizziness / Fainting
Fever / High Temperature
Foreign Body
Headache
Chest Pain / Angina / Heart Attack
Hyperventilation
Body Injury
Arms / Legs Injury
Loss of Consciousness
Mental Disturbance
Nose Problem
Pain
Panic Attack
Seizure
Stroke
Vomiting
Others
FAK Medicine
EMK Medicine
Diagnosis (If Known)
Illness Management Done
Results
Doctors Comments/Recommendations
Doctor's Name
License Number
Contact Details
SCCM Name
SCCM Comments
Signature
Destination
Ground Medical Assistance Required?
IN CASE OF EMERGENCY LANDING OR FLIGHT DIVERSION
SCCM Name
SCCM Staff Number
SCCM Signature
PIC Name
PIC Staff Number
Yellow Security Seal No. 1
Yellow Security Seal No.2
Red Security Seal Number: #1
Red Security Seal Number: #2
Should be Empty:

In-Flight First Aid Incident / Medical Report