Peripheral Vascular Head-to-Toe Assessment Form
Peripheral Vascular Head-to-Toe Assessment Form
Upper Extremity Pulses (Radial, Brachial)
*
Rows
Absent
Weak
Normal
Bounding
Right Radial
1
2
3
4
Left Radial
5
6
7
8
Right Brachial
9
10
11
12
Left Brachial
13
14
15
16
Lower Extremity Pulses (Dorsalis Pedis, Posterior Tibial)
*
Rows
Absent
Weak
Normal
Bounding
Right Dorsalis Pedis
17
18
19
20
Left Dorsalis Pedis
21
22
23
24
Right Posterior Tibial
25
26
27
28
Left Posterior Tibial
29
30
31
32
Capillary Refill Time (Seconds)
*
< 2 seconds
2-3 seconds
> 3 seconds
Edema Assessment
*
None
Mild (1+)
Moderate (2+)
Severe (3+)
Skin Color of Extremities
*
Pink
Pale
Cyanotic
Mottled
Temperature of Extremities
*
Warm
Cool
Cold
Sensation in Extremities
*
Intact
Decreased
Absent
Extremity Hair Distribution
*
Normal
Decreased
Absent
Presence of Ulcers or Lesions
*
None
Present - Upper Extremity
Present - Lower Extremity
Comments or Additional Observations
Submit Assessment
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