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Initial
Contact Information
In an emergency, please notify:____________________________
______________________________________________________
Emergency Medical Assistance Rescue Squad / EMS
/ Ambulance Services:
______________________________________________________
______________________________________________________
Diving Medicine Emergency Contact Information
Divers Alert Network (DAN)
919-684-8111 (toll) or 919-684-4DAN
(collect)
DAN
TravelAssist
215-245-2461 (toll) or 800-DAN-EVAC (toll free)
Other Dive Medicine Reference
______________________________________________________
Recompression Chamber Information
______________________________________________________
DAN
Membership and Insurance information
800-446-2671 or 919-684-2948
Injury
Information
To aid medical personnel, please obtain as much
information as possible from the injured diver or other divers.
Diver's Name___________________________________________
Age___________________________________________________
Address
_______________________________________________
______________________________________________________
Contact
_______________________________________________
Contact Telephone______________________________________
Current Complaint
______________________________________
______________________________________________________
Significant Medical History (medications,
allergies, previous illness or
injuries etc.)
______________________________________________________
______________________________________________________
Dive Profile: DEPTH -- TIME -- S.I.
Dive
#1________________________________________________
Dive #2
________________________________________________
Dive #3
________________________________________________
Exit Water Time
_________________________________________
Breathing Gas: Air -- Nitrox -- Mix _____%
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