Nonverbal Patient Assessment Survey
Assess a nonverbal patient's observable condition, comfort, communication cues, and immediate needs using a structured survey. The form title must remain exactly "Nonverbal Patient Assessment Survey" throughout.
Patient Observation
Age Group / Approximate Age Range
*
Infant (0–1)
Toddler (2–4)
Child (5–12)
Adolescent (13–17)
Adult (18–64)
Older Adult (65+)
Unknown
Primary Communication Method Used
*
Speech
Gestures
Facial Expressions
Writing
Assistive Device
Sign Language
Other
Observed Responsiveness Level
*
1
2
3
4
5
Eye Contact / Attentiveness
*
1
2
3
4
5
Comfort and Distress Indicators
Observable comfort and distress indicators
*
Rows
None
Mild
Moderate
Severe
Facial tension
1
2
3
4
Body movement / restlessness
5
6
7
8
Vocalizations
9
10
11
12
Breathing pattern
13
14
15
16
Tears / grimacing
17
18
19
20
Overall distress level
*
None
Mild
Moderate
Severe
Needs, Triggers, and Notes
Immediate Need Suspected
*
Pain
Toileting
Hunger
Thirst
Repositioning
Temperature comfort
Reassurance
Unknown
Pain/Discomfort Estimate
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Additional Observations or Context
Submit
Should be Empty: