Difficult Airway Assessment Form
Complete this comprehensive airway assessment to evaluate potential airway management challenges.
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age (in years)
*
Airway Management History
*
No previous airway difficulties
Previous difficult intubation
Previous difficult mask ventilation
Other (specify below)
Mallampati Classification
*
Class I
Class II
Class III
Class IV
Mouth Opening (cm)
*
≥ 4 cm
2-3.9 cm
< 2 cm
Thyromental Distance (cm)
*
≥ 6.5 cm
6.0–6.4 cm
< 6.0 cm
Neck Mobility
*
Full range of motion
Reduced extension/flexion
Immobile/limited
Dentition Assessment
*
Normal dentition
Prominent upper incisors
Loose/missing teeth
Edentulous
Airway Obstruction or Anatomical Abnormality
*
None
Obesity
Facial/neck mass
Obstructive sleep apnea
Other (specify below)
Difficult Airway Predictors (Rate each factor)
*
Rows
Low Risk
Moderate Risk
High Risk
Short neck
1
2
3
Large tongue
4
5
6
Receding jaw
7
8
9
Limited mouth opening
10
11
12
Prominent upper teeth
13
14
15
Additional Comments or Observations
Submit Assessment
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