Medical Emergency Data Capture
This form is intended to record medical emergency requirements and alert the concerned team.
Note: For feedback on this initiative and/or survey, as well as to list any other service offering in this portal, please reach out to:
Location: Latitude, Longitude (
Check the boxes below that best describes the condition of the patient according to you
Airway threatened/difficulty breathing (choking, asthma etc)
Unconscious and/or not breathing
Abnormal BP or abnormal pulse or heavy bleeding
Infant less than 1 year old
Poisoning - food/animal bite/others
I'm worried something is seriously wrong with this person
Your assessment of the situation
I think I know what the problem is
I don't know what the problem is
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