BRISTOL-KENDALL FIRE PROTECTION DISTRICT

PATIENT ASSESSMENT
Age:_______
M / F
A-V-P-U
GCS:________
Lbs/Kg:_______
Complaint:__________________________________________________________________________________
___________________________________________________________________________________________
Assessment:_________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Lung Sounds: □ Clear □ Rales □ Wheezes □ Rhonci □ Diminished □ Absent
SpO2 Room Air:________ SpO2 w/O2:________ O2 Rate:______ via:_____________ B/S:___________
Skin Parameters: Temp: □ Norm________ Color: □ Norm_________ Moisture: □ Norm_________
Pupils: □ PERRL □ Constricted L / R
Time

B/P
/
/
/
/

Pulse

□ Midrange L / R □

Resp

Pain

Time

Dilated L / R
B/P
/
/
/
/

Pulse

Resp

Pain

Allergies: □ Denies □ Aspirin □ Penicillin □ Codeine □ Sulfa □ NSAIDS □ Iodine □ Other:_______________
Medical Hx: □ Denies □ HTN □ Diabetes □ Cardiac □ CHF □ MI □ Stroke □ Cancer □ Asthma
□ COPD □ Seizures □ Substance Abuse □ Psych □ Other:_______________________________
_________________________________________________________________________________
Medications:_________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Time

Rhythm (EKG, 12-Lead)

Tx (Pace, Sync, Defib)

mA/Joules

IV Access: Gauge:______ Site:_________________ Rate: □ TKO □ Bolus □ Wide Open Total ml:________
Time

Medication

Dose

Time

Medication

Dose

Cincinnati Stroke Scale: □ Facial Droop □ Arm Drift □ Slurred Speech
CPAP: PEEP Setting:_____ □ CHF Hx □ Pulmonary Edema □ Rales □ Accessory Muscle Usage/Retractions

Patient Info: Name:___________________________________________________ DOB:_____/_____/_______
Address:____________________________________________________________________________
C/S/Z:___________________________________________________ Phone #:___________________

_____________
_____________
______________
______________
______________

__________

____________

____________
____________
______________
____________
____________

tal ml:________

ge/Retractions

_____/_______
______________
______________

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