Patient Name:

________________________
(Last Name)

______________________
(First Name)

Patient Information:

a. Age ____________

b. Sex ___________

c. Past medical History:_________________________________________________________________

d. Current medications:___________________________________________________________________

e. Drug allergies: _______________________________________________________________________

f. Initial B/P:

_____________
(Right Arm)

__________
(Military Time)

___________
(Left Arm)

___________
(Military Time)

YES

NO

g. Pain lasting less than or = 15 minutes

{  }

{  }

h. Pain lasting greater than or = 12 hours

{  }

{  }

i. Systolic B/P greater than or = 185 mmHg

{  }

{  }

J. Diastolic B/P greater than or = 110 mmHg

{  }

{  }

k. Greater than or = 15 mmHg difference in right and left arm systolic pressure

{  }

{  }

l. History of CNS pathology (stroke, seizures, tumor, surgery, etc…) 

{  }

{  }

m. Major surgery or other serious trauma less than or = 6 weeks

{  }

{  }

n.  Bleeding or clotting problems or taking blood thinners

{  }

{  }

o. CPR for greater than or = 10 minutes

{  }

{  }

p. Pregnant or lactating females

{  }

{  }

q. Serious systemic disease (severe kidney or liver disease)

{  }

{  }

r. Advanced or terminal cancer

{  }

{  }