Epidural Sensory Level Assessment Form
Complete this form to record and assess the sensory level following epidural administration. Please use the clinical scales and options provided for each assessment item.
Assessment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Assessor's Name
*
First Name
Last Name
Patient Orientation at Time of Assessment
*
Supine
Sitting
Lateral
Method of Sensory Assessment
*
Cold (ice/alcohol swab)
Pinprick
Touch
Dermatomal Levels Tested (Input Table)
*
Rows
Left Side
Right Side
Cervical (C4–C8)
Thoracic (T1–T12)
Lumbar (L1–L5)
Sacral (S1–S5)
Highest Sensory Block Level Achieved
*
Please Select
T2
T4
T6
T8
T10
T12
L1
L2
Other
Symmetry of Sensory Block
*
Symmetrical
Higher on Left
Higher on Right
Onset Time of Sensory Block (minutes)
*
Regression of Sensory Block (minutes to two-dermatome regression)
*
Assessment Quality (Likert Scale)
*
1
2
3
4
5
Submit Assessment
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