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PATIENT ASSESSMENT SUMMARY: Demographic Information: Patient s Age: Patient s Gender: Male Chief Complaint: History to Include Vital Signs: Physical Findings: Treatment/Interventions: Signatures: Student Signature: Date: Page 1 Virginia Office of Emergency Medical Services www.vdh.virginia.gov/oems EMS.TR.05A Revised: August 2012 Instructor s Signature: Date: Female.

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