Form:CIRM Initial.html
To: telesoccorso@cirm.it;
Subject:CIRM
Msg:
CENTRO INTERNAZIONALE RADIO MEDICO (C.I.R.M.)
(Medical Assistance Form)
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NAME :
INTERNATIONAL CALL SIGN :
FLAG STATE :
VESSEL TYPE:
POSITION OF VESSEL :
PORT OF DEPATURE :
PORT OF DESTINATION :
EXPECTED DAYS TO DESTINATION :
--- SEAFARER INFORMATION ---
NAME AND SURNAME:
DATE OF BIRTH :
RANK :
NATIONALITY :
SEX :
PERSONAL MEDICAL HISTORY:
(Mention any medical problem of the patient with special reference to drug or other allergies, chronic illness medications etc.)
Any other Relevant information:
COMPLAINT DESCRIPTION:
(Describe the symptoms, location of pain, associated symptoms etc. If it is an accident mention how and where the accident took place?)
--- VITALS ---
BLOOD PRESSURE :
PULSE RATE :
BODY TEMPERATURE :
WEIGHT IN KGS :
HEIGHT IN CM :
RESP-RATE MIN :
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CIRM Version