Medical Surgical Exam Assessment
Complete this assessment to document a patient's status and findings for a medical surgical examination.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Brief Reason for Surgical Assessment
*
Medical and Surgical History
*
Allergies (medications, latex, etc.)
Vital Signs
*
Rows
Value
Unit
Temperature
Pulse
Blood Pressure
Respiratory Rate
Oxygen Saturation
Systemic Assessment
*
Rows
Normal
Abnormal
Comments
Cardiovascular
1
2
Respiratory
3
4
Gastrointestinal
5
6
Neurological
7
8
Musculoskeletal
9
10
Integumentary
11
12
Pain Level (0 = No pain, 10 = Worst pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Examiner's Notes and Recommendations
Submit Assessment
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