Medical-Surgical Nursing Adult Patient Assessment Questionnaire
Complete this adult patient assessment form for medical-surgical nursing intake, review, and follow-up planning. Use the exact same title throughout the form.
Patient Identification and Assessment Context
Patient Name
*
Age
*
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Care Setting / Unit
*
Primary Nursing Assessment
Main reason for assessment
*
Current pain severity
*
No pain
1
2
3
4
5
6
7
8
9
Worst possible pain
10
1 is No pain, 10 is Worst possible pain
Overall functional mobility
*
Independent
Needs assistance
Limited
Bedbound
System Review and Risks
Review of Systems and Risk Status
*
Rows
Normal/No Concern
Mild Concern
Moderate Concern
Severe Concern
Breathing / Respiratory
1
2
3
4
Circulation / Cardiovascular
5
6
7
8
Gastrointestinal Status
9
10
11
12
Skin Condition / Integrity
13
14
15
16
Safety / Fall Risk
17
18
19
20
Notable Symptoms or Concerns
Submit Form
Should be Empty: