Medical Exam Room Supply Checklist
Complete this checklist to verify that all required supplies are stocked and the exam room is ready for use.
Exam Room Number or Name
*
Date of Checklist
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Member Name
*
First Name
Last Name
Staff Member Role
*
Please Select
Nurse
Medical Assistant
Physician
Custodian
Other
Medical Supplies Checklist
*
Rows
Present
Low
Missing
Exam Table Paper
1
2
3
Gloves
4
5
6
Hand Sanitizer
7
8
9
Disinfectant Wipes
10
11
12
Tongue Depressors
13
14
15
Gauze Pads
16
17
18
Bandages
19
20
21
Alcohol Swabs
22
23
24
Sharps Container
25
26
27
Biohazard Bags
28
29
30
Are there any maintenance or equipment issues in this room?
*
No issues
Yes (please specify below)
If yes, please describe the maintenance or equipment issues:
Are additional supplies needed?
*
No
Yes (please specify below)
If yes, please list the additional supplies needed:
Additional Comments or Notes
Staff Signature
*
Submit Checklist
Submit Checklist
Should be Empty: