Stroke Nursing Assessment Form
Document key findings of a stroke patient assessment using structured clinical fields.
Patient Full Name
*
First Name
Last Name
Assessment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Level of Consciousness
*
Alert
Verbal response
Pain response
Unresponsive
Facial Droop
*
Absent
Present (Left)
Present (Right)
Arm Motor Function
*
Rows
No drift
Drift
No movement
Left Arm
1
2
3
Right Arm
4
5
6
Leg Motor Function
*
Rows
No drift
Drift
No movement
Left Leg
7
8
9
Right Leg
10
11
12
Speech Assessment
*
Normal
Slurred
Aphasia
Pupil Response
*
Rows
Equal & Reactive
Unequal
Non-reactive
Left Pupil
13
14
15
Right Pupil
16
17
18
Blood Pressure (mmHg)
*
Nurse Comments / Additional Observations
Submit Assessment
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