Form:CIRM Initial.html

To: telesoccorso@cirm.it;
Subject:CIRM <var Callsign> <var Date>
Msg:

CENTRO INTERNAZIONALE RADIO MEDICO (C.I.R.M.)
                (Medical Assistance Form)
------------------------------------------------------------------

NAME : <var Name>
INTERNATIONAL CALL SIGN : <var Callsign>
FLAG STATE : <var Flag>
VESSEL TYPE: <var VesselType>

POSITION OF VESSEL :
<var Position>

PORT OF DEPATURE :
<var PortDeparture>

PORT OF DESTINATION :
<var PortDestination>

EXPECTED DAYS TO DESTINATION : <var DaystoDestination>

--- SEAFARER INFORMATION ---

NAME AND SURNAME: <var NameSurname>
DATE OF BIRTH : <var DOB>
RANK : <var Rank>
NATIONALITY : <var Nationality>
SEX : <var Sex>

PERSONAL MEDICAL HISTORY: 
(Mention any medical problem of the patient with special reference to drug or other allergies, chronic illness medications etc.)

<var MedHIstory>

Any other Relevant information:

<var MoreInfo>

COMPLAINT DESCRIPTION: 
(Describe the symptoms, location of pain, associated symptoms etc. If it is an accident mention how and where the accident took place?)

<var Complaint>

--- VITALS ---

BLOOD PRESSURE : <var BP>
PULSE RATE : <var Pulse>
BODY TEMPERATURE : <var BodyTemp>

WEIGHT IN KGS : <var Weight>
HEIGHT IN CM : <var Heigth>
RESP-RATE MIN : <var RespRate>

-----------
Sent by an amateur radio operator via Winlink
CIRM Version <var Version>