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. Age less than or  = 18 years

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h. Onset of symptoms greater than or  = 3 hours

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i. Patient was asleep when symptoms started

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J. Rapidly improving or minor symptoms

{  }

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k. History of intracranial hemorrhage

{  }

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l. Seizure at onset of symptoms

{  }

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m. Stoke or serious head injury in less than or = 3 months

{  }

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n. Major surgery or other serious trauma in less than or = 2 weeks

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O. GI or urinary tract hemorrhage in less than or = 3 weeks

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

{  }

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

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r. Aggressive treatment to lower B/P (use of vasodilators)

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s. Blood glucose less than or = 60

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t. Blood glucose greater than or = 400

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u. Symptoms of subarchnoid hemorrhage (sudden severe
headache followed by a brief loss of conciousness)

{  }

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v. Arterial puncture at non-compressible site
or lumbar puncture less than or = 1 week

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w. Pregnant or lactating females

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