Pressure Ulcer Risk Assessment Form
Use this form to record pressure ulcer risk factors, assessment findings, and planned preventive actions.
Patient and Assessment Details
Patient Name or Identifier
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name and Title
*
Care Setting / Location
*
Reason for Assessment or Referral
Pressure Ulcer Risk Factors and Current Condition
Mobility Level
*
Fully mobile
Moves with assistance
Bedbound
Wheelchair-dependent
Limited mobility
Other
Able to Reposition Independently
*
Yes
No
Sometimes
Skin Condition / Problem Areas
*
Redness
Non-blanching skin
Broken skin
Swelling
Dry or flaky skin
Moisture-associated skin damage
Heels
Sacrum
Elbows
Hips
Other
Moisture or Incontinence Risk
Urinary incontinence
Fecal incontinence
Sweating
Excess moisture
Diarrhea
Not applicable
Other
Nutrition or Appetite Concern
*
No concern
Reduced appetite
Poor oral intake
Weight loss
Requires nutritional support
Other
Pain or Discomfort at Pressure Points
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Assessment Findings and Plan
Key Assessment Findings by Area/Domain
*
Rows
Observed Issue
Severity
Notes
Sacrum/Coccyx
1
2
Heels
3
4
Elbows
5
6
Shoulders/Back
7
8
Elbow/Ankles
9
10
Mobility
11
12
Nutrition/Hydration
13
14
Skin Moisture
15
16
Overall Risk Level
*
Low
Moderate
High
Very High
Immediate Preventive Actions Planned
Repositioning every 2 hours
Pressure-relieving mattress
Heel offloading
Skin inspection each shift
Moisture management
Nutrition consult
Mobility assistance
Patient/caregiver education
Other
Submit
Should be Empty: