Patient Contacts Tracker
What is your name?
*
Please Select
Breeden
Firestone
Ganzenko
Henry
Leval
Martin
SwederGold
Thibault
Enter the clinical date
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-
Month
-
Day
Year
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Where did you encounter the patient?
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Hospital
Medic unit
Classroom
AFRA
No patients
Which unit were you on?
*
ED
Pediatrics
Geriatrics
L & D
Psychiatric
OR
What was the age of the patient? (You may select more than one option if you are entering multiple patients)
*
Newborn (birth-1 mo)
Infant (2 mo-1 year)
Toddler (1 year-2)
Preschooler (3-5)
School Age (6-12)
Adolescent (13-18)
Adult (19-60)
Geriatric (60+)
Newborn - Select the number of patients you made contact with for the respective chief complaint.
Rows
Number of Patient
Syncope
1
2
3
4
5
Endocrine
1
2
3
4
5
Chest Pain
1
2
3
4
5
Respiratory
1
2
3
4
5
Reproductive
1
2
3
4
5
Genitourinary
1
2
3
4
5
Integumentary
1
2
3
4
5
Cardiovascular
1
2
3
4
5
Gastrointestinal
1
2
3
4
5
Musculoskeletal
1
2
3
4
5
Immune / Lymph
1
2
3
4
5
Altered Mental Status
1
2
3
4
5
Nervous (include psych)
1
2
3
4
5
Infant - Select the number of patients you made contact with for the respective chief complaint.
Rows
Number of Patients
Syncope
1
2
3
4
5
Endocrine
1
2
3
4
5
Chest Pain
1
2
3
4
5
Respiratory
1
2
3
4
5
Reproductive
1
2
3
4
5
Genitourinary
1
2
3
4
5
Integumentary
1
2
3
4
5
Cardiovascular
1
2
3
4
5
Gastrointestinal
1
2
3
4
5
Musculoskeletal
1
2
3
4
5
Immune / Lymph
1
2
3
4
5
Altered Mental Status
1
2
3
4
5
Nervous (include psych)
1
2
3
4
5
Toddler - Select the number of patients you made contact with for the respective chief complaint.
Rows
Number of Patients
Syncope
1
2
3
4
5
Endocrine
1
2
3
4
5
Chest Pain
1
2
3
4
5
Respiratory
1
2
3
4
5
Reproductive
1
2
3
4
5
Genitourinary
1
2
3
4
5
Integumentary
1
2
3
4
5
Cardiovascular
1
2
3
4
5
Gastrointestinal
1
2
3
4
5
Musculoskeletal
1
2
3
4
5
Immune / Lymph
1
2
3
4
5
Altered Mental Status
1
2
3
4
5
Nervous (include psych)
1
2
3
4
5
Preschooler - Select the number of patients you made contact with for the respective chief complaint.
Rows
Number of Patients
Syncope
1
2
3
4
5
Endocrine
1
2
3
4
5
Chest Pain
1
2
3
4
5
Respiratory
1
2
3
4
5
Reproductive
1
2
3
4
5
Genitourinary
1
2
3
4
5
Integumentary
1
2
3
4
5
Cardiovascular
1
2
3
4
5
Gastrointestinal
1
2
3
4
5
Musculoskeletal
1
2
3
4
5
Immune / Lymph
1
2
3
4
5
Altered Mental Status
1
2
3
4
5
Nervous (include psych)
1
2
3
4
5
School age - Select the number of patients you made contact with for the respective chief complaint.
Rows
Number of Patients
Syncope
1
2
3
4
5
Endocrine
1
2
3
4
5
Chest Pain
1
2
3
4
5
Respiratory
1
2
3
4
5
Reproductive
1
2
3
4
5
Genitourinary
1
2
3
4
5
Integumentary
1
2
3
4
5
Cardiovascular
1
2
3
4
5
Gastrointestinal
1
2
3
4
5
Musculoskeletal
1
2
3
4
5
Immune / Lymph
1
2
3
4
5
Altered Mental Status
1
2
3
4
5
Nervous (include psych)
1
2
3
4
5
Adolescent - Select the number of patients you made contact with for the respective chief complaint.
Rows
Number of Patients
Syncope
1
2
3
4
5
Endocrine
1
2
3
4
5
Chest Pain
1
2
3
4
5
Respiratory
1
2
3
4
5
Reproductive
1
2
3
4
5
Genitourinary
1
2
3
4
5
Integumentary
1
2
3
4
5
Cardiovascular
1
2
3
4
5
Gastrointestinal
1
2
3
4
5
Musculoskeletal
1
2
3
4
5
Immune / Lymph
1
2
3
4
5
Altered Mental Status
1
2
3
4
5
Nervous (include psych)
1
2
3
4
5
Adult - Select the number of patients you made contact with for the respective chief complaint.
Rows
Number of Patients
Syncope
1
2
3
4
5
6
7
8
9
10
Endocrine
1
2
3
4
5
6
7
8
9
10
Chest Pain
1
2
3
4
5
6
7
8
9
10
Respiratory
1
2
3
4
5
6
7
8
9
10
Reproductive
1
2
3
4
5
6
7
8
9
10
Genitourinary
1
2
3
4
5
6
7
8
9
10
Integumentary
1
2
3
4
5
6
7
8
9
10
Cardiovascular
1
2
3
4
5
6
7
8
9
10
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
Immune / Lymph
1
2
3
4
5
6
7
8
9
10
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
Geriatric - Select the number of patients you made contact with for the respective chief complaint.
Rows
Number of Patients
Syncope
1
2
3
4
5
6
7
8
9
10
Endocrine
1
2
3
4
5
6
7
8
9
10
Chest Pain
1
2
3
4
5
6
7
8
9
10
Respiratory
1
2
3
4
5
6
7
8
9
10
Reproductive
1
2
3
4
5
6
7
8
9
10
Genitourinary
1
2
3
4
5
6
7
8
9
10
Integumentary
1
2
3
4
5
6
7
8
9
10
Cardiovascular
1
2
3
4
5
6
7
8
9
10
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
Immune / Lymph
1
2
3
4
5
6
7
8
9
10
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
Please use the space below to provide any additional information you wish to share with Academy staff.
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