Tissue and Eye Screening Information Sheet
1-800-241-4483
Tissue & Eye Screening Information Sheet Please call within ONE HOUR after Asystole
? Reason for admission/circumstances surrounding death:
1. DNR? 2. Comfort Measures only? 3. If arrest not witnessed, last known time alive? 4. ACLS drugs used and amount if given? 5. If trauma death, what type of injuries are present?
? Past Medical History:
? Antibiotics given:
Date started:
? Most recent Labs, CXRs, Culture reports: ? WBC Count with Bands (if available):
Lab date & time:
? Current Hospital Medications:
Home Medications:
? IV Fluids, Crystalloids given in the last hour: ? Colloids given in the last 48 hours: ? Blood Products given in the last 48 hours:
? Vital Signs (HR, RR, BP, Temp): ? Height & Weight:
? Medical Examiner Case? ? Funeral Home? ? EMS Service Transported Patient if ................
................
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