Neurovascular Assessment Checklist Form

Neurovascular Assessment Checklist Form
Complete this checklist to document the patient's neurovascular status as part of the clinical evaluation.
Level of Consciousness
Orientation Status
Pupil Size and Reaction
Rows Size (mm) Reaction to light
Left
Right
Motor Function (Limb Movement)
Rows Strength Movement
Left Arm
Right Arm
Left Leg
Right Leg
Sensory Function (Touch Sensation)
Rows Sensation
Left Arm
Right Arm
Left Leg
Right Leg
Pain Assessment (0 = No pain, 10 = Worst pain)

0
1
2
3
4
5
6
7
8
9
10
0 is No pain, 10 is Worst pain
Capillary Refill Time (seconds)
Peripheral Pulse Quality

Limb Temperature and Color

Select theme:

Rows	Size (mm)	Reaction to light
Left
Right