BRISTOL-KENDALL FIRE PROTECTION DISTRICT

PATIENT ASSESSMENT

Age:_______ M / F A-V-P-U GCS:________ Lbs/Kg:_______

Complaint:__________________________________________________________________________________
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Assessment:_________________________________________________________________________________
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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 □ Midrange L / R □ Dilated L / R

Time B/P Pulse Resp Pain Time B/P Pulse Resp Pain
/ /
/ /
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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:_______________________________
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Medications:_________________________________________________________________________________
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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 #:___________________
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tal ml:________

ge/Retractions

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