Type of Injury Type of Disease Amputation Head injury Allergic reaction Infectious / Parasitic Bruise Heat stress / exhaustion Dermatitis / Loss of consciousness – Exzema Burns Internal injury fainting, seizure Disease of Cut / Laceration Poisoning / toxic effects Psychological circulatory system Dislocation of substance Respiratory irritation / disease Disorders of the Foreign body Sprains / strains Other diseases (please specify) muscles, Fracture Other (please specify) tendons & Grazes, scratches/ ………..………………………… soft tissues abrasions …………………………….. Eye Disorders Hearing loss Hernia BODILY LOCATION OF INJURY - Indicate left or right as appropriate as L or R next to body part
Type of Injury Amputation Bruise Burns Cut / Laceration Dislocation Foreign body Fracture Grazes, scratches/ abrasions Head injury Heat stress / exhaustion Internal injury Poisoning / toxic effects of substance Sprains / strains Other (please specify) …………………………….. Type of Disease Allergic reaction Dermatitis / Exzema Disease of circulatory system Disorders of the muscles, tendons & soft tissues Eye Disorders Hearing loss Hernia Infectious / Parasitic Loss of consciousness – fainting, seizure Psychological Respiratory irritation / disease Other diseases (please specify) ………..………………………… BODILY LOCATION OF INJURY - Indicate left or right as appropriate as L or R next to body part
wfd_host_induction_kit_1.docx