Adrian Empire PHYSICKER : User Guide : Page 5

Imperial Physicker's Manual Page 5 of 5

as adopted August 1992, amended December 1998

A

PPENDIX

C: M

EDICAL

I

NCIDENT

F

ORM

This form is intended to gather voluntary medical information for members of the Adrian Empire, Inc. to aid

emergency medical personnel if ever a need arises.

Date: __________________________________Time: _______________________________________

Location:_______________________________ ____________________________________________

Mundane name: _________________________ Persona: _____________________________________

Type of injury: _______________________________________________________________________

___________________________________________________________________________________

How injury occurred: __________________________________________________________________

___________________________________________________________________________________

How was consent to treat obtained: ! Verbal ! Unconscious victim ! Victim declined treatment

If victim was a minor, from whom did you obtain consent?

Name: _________________________________ Relationship: _________________________________

How treated: _________________________________________________________________________

___________________________________________________________________________________

Any follow-up: _______________________________________________________________________

___________________________________________________________________________________

Chartered Subdivision:____________________ Physiker:_____________________________________