Free Medical Checklist Template
Medical Checklist
|
Name |
Address |
Company |
|---|---|---|
|
[your name] |
[your company address] |
[your company name] |
Medical History Acknowledged:
|
YES |
NO |
|
|
Past Illnesses |
|
|
|
Surgeries/Hospitalizations |
|
|
|
Chronic Conditions |
|
|
|
Allergies to Medications |
|
|
|
Current Medications Cross-Checked |
|
|
Medication Reconciliation:
|
YES |
NO |
|
|
Medication & Dosage Verified |
|
|
|
Administration Frequency Confirmed |
|
|
|
Side Effects Noted |
|
|
Symptom Evaluation:
|
YES |
NO |
|
|
Description of Symptoms Logged |
|
|
|
Symptoms Onset Time Identified |
|
|
|
Symptom Frequency and Duration Recorded |
|
|
|
Severity of Symptoms Assessed |
|
|
Immediate Intervention Checklist:
|
YES |
NO |
|
|
Airway Management Evaluated |
|
|
|
Oxygen Therapy Initiated |
|
|
|
IV Fluids Requirement Checked |
|
|
|
Bronchodilator Need Assessed |
|
|
|
Hypoglycemia Treatment Provided |
|
|
|
Opioid Overdose Response Activated |
|
|
|
Body Temperature Regulation Addressed |
|
|
Post-Resuscitation Protocol:
|
YES |
NO |
|
|
Vital Signs Re-evaluated |
|
|
|
Emergency Medications Administered |
|
|
|
ECG Conducted |
|
|
|
Pregnancy Test Done |
|
|
|
Review of All Tests & Imaging |
|
|
Continued Monitoring & Planning:
|
YES |
NO |
|
|
Serial Exams Scheduled |
|
|
|
Patient & Family Care Plan Discussion |
|
|
|
Emergency Unti Documentation Fulfilled |
|
|
Healthcare Professional Verification:
|
YES |
NO |
|
|
Checklist Completion Confirmed |
|
|
|
Professional's Signature Box Checked |
|
|
|
Date & Time of Completion Noted |
|
|
