Peripheral Vascular Emergency Assessment
Patient Full Name
*
First Name
Last Name
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Presenting Symptoms
*
Affected Limb(s)
*
Left Leg
Right Leg
Left Arm
Right Arm
Both Legs
Both Arms
Pain Level (0-10)
*
1
1
2
3
4
Best
5
1 is , 5 is Best
Skin Color Changes
*
Normal
Pale
Cyanotic
Red
Mottled
Temperature of Affected Limb(s)
*
Normal
Cold
Warm
Hot
Pulse Presence
*
Present
Absent
Weak
Capillary Refill Time (seconds)
*
Edema (Swelling)
*
None
Mild
Moderate
Severe
Sensation in Affected Limb(s)
*
Normal
Decreased
Absent
Motor Function in Affected Limb(s)
*
Normal
Decreased
Absent
Additional Notes
Submit
Should be Empty: