Hematoma Assessment Form
Complete this form to assess and document hematoma characteristics and relevant observations.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Hematoma
*
Please Select
Arm
Leg
Torso
Head/Neck
Other
Approximate Size of Hematoma
*
Small (<2 cm)
Medium (2–5 cm)
Large (>5 cm)
Color of Hematoma
*
Red
Purple/Blue
Green/Yellow
Brown
Tenderness to Touch
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Swelling Present?
*
Yes
No
Onset of Hematoma
*
Sudden
Gradual
Unknown
Progression Since Onset
*
Improved
Unchanged
Worsened
Associated Symptoms (Select all that apply)
*
Pain
Numbness
Limited Movement
None
Other
Overall Severity (1 = Mild, 10 = Severe)
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Submit Assessment
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