Critical Condition Assessment Form
Complete this form to systematically assess and document a critical condition or emergency situation.
Full Name of Person Being Assessed
*
First Name
Last Name
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident or Assessment
*
Contact Number (if available)
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Critical Symptoms or Signs
*
Unconsciousness
Severe bleeding
Breathing difficulties
Chest pain
Seizure
Severe allergic reaction
Other
Severity Assessment
*
Mild
1
2
3
4
5
6
7
8
9
Critical
10
1 is Mild, 10 is Critical
Risk Factors Present
Known heart condition
Diabetes
Respiratory disease
Recent surgery
None
Other
Assessment Observations
*
Rows
Normal
Abnormal
Not Assessed
Airway
1
2
3
Breathing
4
5
6
Circulation
7
8
9
Consciousness
10
11
12
Skin color
13
14
15
Immediate Actions Taken
Called emergency services
Provided CPR
Applied first aid
Monitored vital signs
Other
Recommendations or Next Steps
Assessor's Name
*
Assessor's Role/Position
Additional Comments
Submit Assessment
Should be Empty: