Emergency Medical Patient Assessment Practice Form
Use this form to practice documenting an emergency medical patient assessment scenario. Keep responses concise and scenario-appropriate.
Patient & Scenario Details
Patient age
*
Patient sex/gender
Female
Male
Intersex
Non-binary
Prefer not to say
Chief complaint
*
Location/type of incident
*
Please Select
Home
Workplace
Public place
Vehicle
Sports setting
Other
Scenario severity / urgency level
*
Please Select
Low
Moderate
High
Critical
Assessment Findings
Primary Assessment Findings
*
Rows
Normal
Mild Concern
Moderate Concern
Severe Concern
Airway status
1
2
3
4
Breathing status
5
6
7
8
Circulation/perfusion
9
10
11
12
Level of consciousness
13
14
15
16
Pain Score
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Visible symptoms or signs
Shortness of breath
Cyanosis
Bleeding
Swelling
Rash
Vomiting
Fever
Altered speech
Other
Brief assessment notes
Intervention and Outcome
Initial actions taken
*
Call for help
Position patient
Basic first aid
Monitor vitals
Prepare transport
No action yet
Other
Disposition / next step
*
Continue monitoring
Transfer to higher care
Transport arranged
Exercise complete
Other
Outcome / instructor feedback
Submit Form
Should be Empty: