Shunt Evaluation Assessment Form
Please complete this form to assess the function and status of a patient's shunt system.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shunt Type and Model
*
Presenting Symptoms (select all that apply)
*
Headache
Nausea/Vomiting
Lethargy
Irritability
Seizures
Fever
Other
Physical Examination Findings
*
Rows
Normal
Abnormal
Fontanelle (if applicable)
1
2
Shunt tract
3
4
Abdominal site
5
6
Neurological exam
7
8
Imaging Findings
*
Rows
Normal
Abnormal
CT/MRI - Ventricular size
9
10
Shunt position
11
12
Signs of infection
13
14
Assessment of Shunt Function
*
Not functioning
1
2
3
4
Normal function
5
1 is Not functioning, 5 is Normal function
Overall Assessment
*
Shunt functioning properly
Possible shunt malfunction
Uncertain—further evaluation needed
Comments / Recommendations
Evaluator Name and Title
*
Submit Assessment
Should be Empty: