Secondary Assessment First Aid Checklist Form
Document your secondary assessment findings after an incident using this checklist-oriented form.
Date and Time of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Assessor's Full Name
*
First Name
Last Name
Initial Observations (Check all that apply)
*
Conscious
Responsive
Breathing Normally
Bleeding
Obvious Injury
Other
Head-to-Toe Assessment Checklist
*
Head/Neck Checked
Chest Checked
Abdomen Checked
Pelvis/Hips Checked
Arms/Hands Checked
Legs/Feet Checked
Skin Condition Observed
*
Normal
Pale
Cool/Clammy
Warm/Dry
Flushed
Other
Level of Consciousness (AVPU Scale)
*
Alert
Verbal Response
Pain Response
Unresponsive
Pain Level (0 = No Pain, 10 = Worst Possible)
*
No Pain
0
1
2
3
4
5
6
7
8
9
Worst Possible
10
0 is No Pain, 10 is Worst Possible
Breathing Quality
*
Normal
Shallow
Rapid
Labored
Irregular
Circulation Observations (Check all that apply)
*
Normal Pulse
Weak Pulse
Rapid Pulse
Slow Pulse
Capillary Refill >2s
Other
Additional Notes / Findings
Submit Assessment
Should be Empty: