Prehospital Patient Assessment Checklist
A structured checklist for prehospital patient assessment. Please complete each section to ensure a thorough evaluation.
Patient Initials
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 (AVPU)
*
Alert
Responds to Voice
Responds to Pain
Unresponsive
Primary Assessment Checklist
*
Airway Clear
Breathing Adequate
Circulation Stable
Disability Checked
Exposure/Environment Managed
Skin Signs
Normal (warm, pink, dry)
Pale
Cool/Clammy
Flushed
Obvious Injuries/Conditions (select all that apply)
Bleeding
Fractures/Suspected Fractures
Burns
Medical Alert Bracelet/Necklace
None Observed
Pain Level (0 = No pain, 10 = Worst pain)
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Interventions Performed
Oxygen Administered
Bleeding Controlled
Splint Applied
Patient Repositioned
Other
Overall Patient Condition
*
Stable
Potentially Unstable
Unstable
Additional Notes
Submit Assessment
Should be Empty: