Nursing Assessment Patient Record Form
Record patient assessment details, vital signs, symptoms, history, functional status, and nursing notes for clinical care.
Patient Identification and Visit Context
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Sex / Gender Identity
*
Female
Male
Non-binary
Prefer not to say
Prefer to self-describe
Phone 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
Location / Unit / Ward
*
Assessor Nurse Name / Role
*
Chief Complaint and Present Illness
Chief Complaint
*
Onset / Date Started
-
Month
-
Day
Year
Date
Symptom Duration
Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Symptom Description
Aggravating Factors
Activity
Movement
Eating
Stress
Lying Down
Coughing
Deep Breathing
Other
Relieving Factors
Rest
Medication
Position Change
Ice/Heat
Hydration
Deep Breathing
Other
Recent Changes in Condition
Vital Signs and Objective Assessment
Temperature (°C)
*
Pulse / Heart Rate (bpm)
*
Respiratory Rate (breaths/min)
*
Blood Pressure
*
Oxygen Saturation (%)
*
Pain Score
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Weight (kg)
*
Height (cm)
*
Other Objective Measurements / Clinical Observations
Abnormal Findings and Nursing Notes
Pain and Symptom Review
Pain Location
Pain Type / Quality
Please Select
Sharp
Dull
Throbbing
Burning
Cramping
Aching
Stabbing
Pressure
Other
Pain Timing / Pattern
Please Select
Constant
Intermittent
Worsening
Improving
Triggered by Activity
Triggered by Movement
At Rest
Other
Pain Scale
1
2
3
4
5
6
7
8
9
10
Associated Symptoms
Swelling
Redness
Stiffness
Numbness
Tingling
Weakness
Sensitivity to Touch
Other
Breathing Difficulty
No
Yes
Not Sure
Cough
No
Yes
Not Sure
Symptom Review
Please Select
Nausea/Vomiting
Dizziness
Fatigue
Fever
Other Relevant Symptom
None
Medical History and Current Treatment
Known Allergies
Allergy Severity / Reaction
Current Medications
Past Medical History
Past Surgical History
Family History Relevant to Care
Recent Hospitalizations or Emergency Visits
No
Yes
Details of Recent Hospitalizations or Emergency Visits
Immunization Status
Please Select
Up to date
Partially up to date
Unknown
Not relevant
Other
Functional Status, Lifestyle, and Nursing Risks
Mobility / Ambulation Status
*
Independent
Uses cane
Uses walker
Uses wheelchair
Bedbound
Other
Ability to Perform Activities of Daily Living
*
Fully independent
1
2
3
4
5
6
7
8
9
Fully dependent
10
1 is Fully independent, 10 is Fully dependent
Diet / Nutrition Status
*
Regular diet
Modified diet
Poor appetite
NPO
Tube feeding
Other
Diet / Nutrition Notes
Sleep Pattern
Normal
Difficulty falling asleep
Frequent awakenings
Sleeping too much
Insomnia
Other
Elimination Concerns
None
Urinary frequency
Urinary urgency
Incontinence
Constipation
Diarrhea
Other
Tobacco / Alcohol / Substance Use
No current use
Tobacco use
Alcohol use
Cannabis use
Non-prescribed substance use
Former use
Other
Fall Risk
*
Low
Moderate
High
Skin Integrity / Pressure Injury Risk
*
Intact
At risk
Redness present
Open area / wound present
Existing pressure injury
Other
Other Nursing Risk Factors / Notes
Nursing Observations and Care Priorities
Nurse’s Assessment Findings
*
Priority Nursing Problems / Concerns
*
Pain
Risk of Falls
Skin Integrity Risk
Breathing Difficulty
Nausea or Vomiting
Anxiety
Mobility Limitation
Poor Nutrition
Other
Immediate Interventions Provided
Escalation / Referral Need
*
None
Physician notified
Urgent review needed
Specialist referral recommended
Other
Follow-up Plan
*
Additional Remarks
Submit Assessment
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