Emergency Services Health Assessment Form

Emergency Services Health Assessment Form
Please complete this form to provide a thorough assessment of the patient's condition and incident details for emergency services.
Responder Full Name
First NameLast Name
Responder Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Date and Time of Assessment
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Patient Full Name
First NameLast Name
Patient Age
Incident Location (Address)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Chief Complaint (describe main issue or reason for call)
Assessment of Vital Signs
Rows Value
Blood Pressure (mmHg)
Pulse (bpm)
Respiratory Rate (breaths/min)
Temperature (°C or °F)
Oxygen Saturation (%)
Level of Consciousness (AVPU Scale)
Type of Injury or Illness
Other
Relevant Medical History (e.g., diabetes, heart disease)
Known Allergies
Current Medications
Should be Empty:

Rows	Value
Blood Pressure (mmHg)
Pulse (bpm)
Respiratory Rate (breaths/min)
Temperature (°C or °F)
Oxygen Saturation (%)