Hypovolemic Shock Assessment Form
Use this form to systematically assess patients for hypovolemic shock based on clinical presentation, vital signs, and risk factors.
Patient Full Name
*
First Name
Last Name
Patient Age
*
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Assessment
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Presenting Symptoms (Select all that apply)
*
Rapid heartbeat (tachycardia)
Low blood pressure (hypotension)
Pale or cool skin
Weak pulse
Confusion or altered mental state
Decreased urine output
Rapid breathing
Other
Vital Signs
*
Rows
Value
Systolic Blood Pressure (mmHg)
Heart Rate (bpm)
Respiratory Rate (per min)
Temperature (°C)
Oxygen Saturation (%)
Estimated Blood Loss
*
< 750 mL (Class I)
750–1500 mL (Class II)
1500–2000 mL (Class III)
> 2000 mL (Class IV)
Unable to estimate
Risk Factors Present (Select all that apply)
Recent trauma or surgery
Active bleeding
Severe dehydration
Burns
Gastrointestinal losses (vomiting/diarrhea)
Other
Level of Consciousness
*
Unresponsive
1
2
3
4
Alert
5
1 is Unresponsive, 5 is Alert
Skin Condition
*
Warm and dry
Cool and clammy
Pale
Mottled
Other
Clinical Impression of Shock Severity
*
No shock
Mild shock
Moderate shock
Severe shock
Additional Notes / Interventions
Submit Assessment
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