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Nursing Assessment Form Template

Streamline Patient Evaluations with Our Nursing Assessment Template

Feeling overwhelmed by the patient evaluation process? This nursing assessment form template is designed for registered nurses like you, helping you efficiently document patient symptoms and care needs. With features that promote quick data entry, improve communication with healthcare teams, and ensure compliance with medical standards, this template simplifies your workflow. Experience a more organized approach to patient assessments and enhance your practice with this versatile tool-explore the live template now.

Use this Template (FREE) Live Preview
Full name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary phone number
Home address
Emergency contact full name
Emergency contact phone
Emergency contact relationship to patient
Spouse/Partner
Parent
Sibling
Child
Friend
Caregiver
Other
Please Specify:
What is your main reason for today's visit?
When did this issue begin?
Current pain level
No pain
Mild (1-3)
Moderate (4-6)
Severe (7-8)
Very severe (9-10)
Not applicable
Please select any chronic conditions that apply
Please Specify:
List past surgeries or hospitalizations (with dates if known)
Allergies (select all that apply)
No known drug allergies
Medication allergy
Food allergy
Latex allergy
Environmental allergy
Other
Please Specify:
Please list specific allergies and reactions
Current medications (include dose and frequency if known)
Are you currently pregnant?
Yes
No
Not applicable
Height (please include units)
Weight (please include units)
Mobility status
Independent
Needs some assistance
Uses mobility aid
Dependent
Not applicable
Have you fallen in the past 6 months?
Yes
No
Not sure
Substance use (select all that apply)
Tobacco
Alcohol
Recreational drugs
None
Prefer not to say
Over the past 2 weeks, how often have you felt down, depressed, or hopeless?
Very rarely
Rarely
Sometimes
Often
Very often
In the past 14 days, have you had fever, cough, or shortness of breath?
Yes
No
Insurance provider
Type your full name as signature
Date signed
I consent to a nursing assessment and the necessary care as discussed.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration featuring a nursing assessment form with detailed sections and headings, emphasizing healthcare documentation.

When to use this form

Use this form at intake, shift handoff, or before a care transition. It helps you capture baseline vitals, chief concern, meds, and function fast, so you can triage and plan care. In clinics, home health, LTC, or the ED, it fits into new visits, readmissions, and telehealth check-ins. For a full picture on arrival, pair it with a Patient assessment form. When you need a verified history for insurance or HR files, add a Statement of health form. If a provider is shaping next steps, share your notes alongside a Doctor diagnosis form to align treatment. The result is fewer gaps, safer handoffs, and consistent documentation you can audit.

Must Ask Nursing Assessment Questions

  1. What brought you here today, and when did your symptoms start?

    This captures the chief concern and onset to guide triage and urgency. Knowing timing helps you spot red flags and set priorities for care.

  2. Do you have any diagnosed conditions or allergies, and what are your current medications (name, dose, schedule)?

    This reduces medication errors and adverse reactions. It also flags interactions and informs monitoring plans.

  3. Have you noticed recent changes in appetite, weight, or hydration?

    Nutrition shifts can signal underlying problems and risk of dehydration or malnutrition. If follow-up tracking is needed, attach a Diet journal form to monitor trends.

  4. How would you rate your pain now (0-10), and what makes it better or worse?

    A numeric rating standardizes severity and response to treatment. Triggers and relievers help you tailor interventions and evaluate outcomes.

  5. How do these symptoms affect your daily activities such as walking, bathing, or dressing?

    Functional impact shows the level of assistance and safety needs. For detailed work capacity, pair this intake with a Functional capacity evaluation form to plan therapy or equipment.

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