Animal Bite Consultation Sheet

PATIENT DETAILS

Name:

IC:

Date:

Guardian's Name:

Age:

Gender:

Occupation:

Address:

Contact No:

EXPOSURE

Date of Exposure:

Place of Exposure:

Type of Animal:

Ownership: Can animal be observed for 14 days?

Animal Status:

Animal Behavior & Incident Description:

Behavior Before Bite:

Behavior During Bite:

Behavior After Bite:

Additional Incident Details (Optional):

Exposure Site:

Was the skin broken? Did the wound bleed spontaneously?

Other Complaint:

PAST MEDICAL HISTORY

EXAMINATION

Co-morbid:

Drug Allergy:

BP

PR

RR

T

WT

Exposure Wound Category:

Other Medical Condition / Treatment:

Diabetes Hypertension Heart Disease CKD HIV/AIDS Cancer Steroid Use Immunosuppressive

Vaccination History Against Rabies: Tetanus Status:

DOCTOR ASSESSMENT

Physical Examination:

Assessment:

Diagnosis:

DOCTOR'S ORDERS

Orders:

Rabies Vaccine

Rabies Vaccine Regimen:

ERIG

ERIG Plan: ERIG Dose & Route:

IF (Infiltration) Dose

mL

IM (Intramuscular) Dose

mL

Enter the actual ERIG amount for each route. Either or both routes may be used.

Tetanus / ATS / TT

ATS Dose: TT Dose:

Antibiotics

Medications:

Plan: Referral Plan: Follow-up Date: Doctor:

Doctor's Digital Signature

Sign using stylus, touch, or mouse

Remarks / Other Plan:

TREATMENT COUNSELING / PATIENT DECISION

Treatment Status:

Refused Treatment:

Reason for Refusal:

Waiver Signed

PROVIDENCE ANIMAL BITE & MEDICAL CLINIC