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Rate:
DNormal DAlert D NormaJIPEARL 0 o Cool oPale
DAbnormal (explain): DResponsive to Voice 0 Dilated D DWann DCyanotic
oRegular DResponsive to Pain 0 Constricted 0 oMoist oFlushed
DShallow DUmcsponsive 0 Sluggish D DOry oJaundiced
DLabored D No Reaction 0
Rate: DNonnal DAlert D NonnalIPEARL D DCooI oPale
DAbnormal (explain): DResponsive to Voice D Dilated 0 DWarm DCyanotic
DRegular DResponsive to Pain D Coostridied 0 oMoist OFlwdled
o Shallow DUmesponsive D Sblggish D DDJy D1aundiced
oLabored 0 No Reaction 0
Rate: o Normal DAlert D NCJllJUIIIPEARL 0 oCool IJPale
oAbnormal (e:xpIain): oResponsive to Voice 0 Dilated 0 oWarm DCyanotic
DRegular oResponsive to Pain 0 Constricted 0 oMoist oFlushed
o Shallow oUnresponsive D Sluggish D DOry DJaundiced
DLabored 0 No Reaction D
Narrative:
such lreatmeot was advised by the EMTs. I hereby release such persons
Signatures:
from liability for respecting and following my expressed wishes: Disp#_ _MA LiC#
Signed: Date
Disp#_ _MALiC#
Witness: Date