AVPU Scale Medical Assessment Form

AVPU Scale Medical Assessment Form
Document AVPU responsiveness level and related observations for clinical assessment.
Patient/Subject Initials or ID
Assessment Date and Time
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Assessor Name
AVPU Responsiveness Level
Detailed Observation Notes
Pupil/Neurologic Observations
Rows Left Pupil Right Pupil Reaction
Size (mm)
Reaction to Light
Contributing Factors (select all that apply)
Other
Immediate Action Taken
Follow-up / Transport Disposition
Other
Should be Empty:

Select theme:

Rows	Left Pupil	Right Pupil	Reaction
Size (mm)
Reaction to Light