Parkland College

Assessment Worksheet
Medical
Assessment #:
Clinical Area: _________________________________ (For Lead Instructor only)

Student Name: Performed by Student

Meds:
Date:

Patient Age: _________ Gender: __________

Scene Size Up: Advanced Airway:

CPR/BVM:
Chief Complaint: OTHER:

General Impression:

Initial Assessment
Level of Consciousness:
Pathology/Complaint
Airway: Trauma
Obstetrics
Breathing: Rate Mental Health
Chest Pain
Quality:________________ Abdominal Pain
Altered Mental State
Dyspnea
Ventilation/Oxygenation Instructions: ___________________________
Syncope
Circulation: Pulses: Skin: _____________________ Other

Bleeding: __________________________________________

Critical: Sick: Not Sick:

Focused History and Physical Exam

History of present Illness:

Onset: Associated Symptoms:

Provocation/Palliative:

Quality Pertinent Positive Findings:

Region/Radiation:

Severity: Pertinent Negative Findings:

Time:

Glasgow Coma Scale:

Best eye opening:

Best motor response

Best verbal response: __________

 Parkland College
Assessment Worksheet
MEDICAL
SAMPLE History:
Signs & Symptoms: Pertinent Past History:

Allergies: Last Meal:

Medications: Events:

Focused Physical Exam

Vital Signs:
BP: _____________ Pulse: ___________ Respirations: ____________

Skin Color, Condition, and Temp: _______________________________ Weight:

Oxygen Saturation: _________ Blood Glucose: _______________ Pain Scale: ________

Detailed Assessment:
Head: Neck:

Face: Chest:

Eyes: Abdomen:

Ears: Pelvis:

Nose: Legs:

Mouth: Arms:

Back:

Management Priorities:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Probable Field Diagnosis:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Patient Outcome:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Student Signature: ____________________________________________

Preceptor Signature: ________________________________________