Anemia Nursing Assessment Form
Complete this form to document a comprehensive nursing assessment for patients with suspected or diagnosed anemia.
Patient Full Name
*
First Name
Last Name
Age
*
Gender
*
Male
Female
Other
Presenting Symptoms (select all that apply)
*
Fatigue
Shortness of breath
Paleness
Dizziness
Rapid heartbeat
Headache
Other
Relevant Medical History
*
Previous anemia diagnosis
Chronic kidney disease
Recent surgery or trauma
Menstrual disorders
Gastrointestinal bleeding
No relevant history
Dietary Assessment
*
Vegetarian/Vegan
Low iron intake
Balanced diet
Other
Physical Findings
*
Pale conjunctiva
Brittle nails
Glossy tongue
Spoon-shaped nails
No abnormal findings
Fatigue Severity (past week)
*
None
0
1
2
3
4
5
6
7
8
9
Severe
10
0 is None, 10 is Severe
Bleeding or Bruising History
*
No history
Recent unexplained bruising
Frequent nosebleeds
Heavy menstrual bleeding
Gastrointestinal bleeding
Current Medications (select all that apply)
*
Iron supplements
Vitamin B12
Folic acid
Anticoagulants
No current medications
Other
Submit Assessment
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