Homeostasis Monitoring Checklist
Complete this checklist to systematically assess and monitor key indicators of homeostasis.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient/Client Full Name
*
First Name
Last Name
Observer's Full Name
*
First Name
Last Name
Temperature (°C)
*
Pulse Rate (beats per minute)
*
Respiratory Rate (breaths per minute)
*
Blood Pressure (mmHg)
*
Skin Condition
*
Warm and dry
Cool and clammy
Hot and flushed
Pale
Other
Level of Consciousness
*
Alert
Drowsy
Unresponsive
Confused
Signs of Dehydration or Overhydration
*
Dry mucous membranes
Sunken eyes
Edema (swelling)
Normal hydration
Other
Fluid Intake and Output (ml)
Rows
Intake
Output
Last 8 hours
Last 24 hours
Additional Observations/Notes
Submit Checklist
Should be Empty: