Pre Flight Asssesment Name Passport No Gender Age DOB Nationality Weigh in KG Medevac Route From To Reason for TransferHigher level of careSpecialty carePatient's family Request Diagnose Vital Sign: GCS E V M Blood Pressure /MMhg Pulse ×/ minutes Temp (°C) Respiration X/minutes Spo2 Spo2 (%) On RHYTHMNormal Sinus rhythmArrhythmia without Hemodynamic impactArrhythmia with Hemodynamic Impact RESPIRATIONNo impairment, SP02 > 95% on room AirNeed Inhalation or high flow OxygenRespirator ( CPAP, BiPAP ) , NIVMechanical ventilator BLOOD PRESSUREStableStable, but require supportRequire maximum support Dopamine ug/kg/min Nor-Epinephrine ug/kg/min Dobutamine ug/kg/min Epinephrine ug/kg/min MOBILAZATIONFull mobilized of maximum 1 peripheral venous accessPartial mobilized of maximum 1 peripheral or central venous access plus urine catheter or oxygen maskNon-Mobilized, bulky bandages, extension, chest-tube INFECTIOUSNon- InfectiousInfectious by blood or specimeninfectious by aerosol or contactUnknown communicable disease COOPERATIONFull cooperativePartial cooperative or somnolentNon-cooperative or unconsciousTemper / combative / violent CONTRAINDICATIONS / HIGH RISK TO AIR MEDICAL TRANSPORTIs this patient in full arrest and resuscitated within 24 hrs?Is this terminally ill patient? ( end stage cancer, vegetative deep coma etc)Is this patients with uncontrollable, unstable or abnormal vital signs?Is this a uncontrollable, combative patient?Is this patients with major and or multiple svstem trauma?Unstable patient, who requires immediate lifesaving procedure ( emergency laparotomy, craniotomy etc ) which could be performed at the sending centre? Date Time: Referring Hospital
