Peripheral Circulation Assessment Form
Complete this assessment to record key indicators of peripheral circulation. Please provide accurate observations for clinical review.
Patient Name
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessment Context
*
Please Select
Routine check
New symptom evaluation
Post-operative review
Follow-up
Other
Primary Symptom
*
Pain
Numbness
Coldness
Discoloration
Swelling
Other
Observed Skin Color
*
Normal
Pale
Cyanotic
Mottled
Other
Peripheral Temperature
*
Warm
Cool
Cold
Capillary Refill Time (seconds)
*
< 2
2–4
> 4
Pulse Quality (Likert Scale)
*
Absent
1
2
3
4
Normal
5
1 is Absent, 5 is Normal
Assessment Table: Compare Left and Right Limbs
*
Rows
Left
Right
Pulse present
1
2
Skin temperature normal
3
4
Capillary refill <2s
5
6
No swelling
7
8
Additional Notes
Submit Assessment
Should be Empty: