Clinical Assessment Form
Clinical Assessment Form
Use this quick form to assess the patient's health and identify any areas needing medical attention.
Personal Details
Name
Age
Gender
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Male
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Female
Phone Number
Assessment Checklist
1. General Health
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Patient appears well and alert
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No signs of distress
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Vital signs are within normal range
Reported symptoms
2. Medical History
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No known chronic conditions
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Known conditions
Known Conditions
List the known conditions.
Current Medications
List the current medications.
Allergies (if applicable)
3. Physical Examination
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Skin is clear, no rashes or lesions
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Eyes, ears, nose, and throat appear normal
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Heart and lungs sound normal
Other findings
4. Pain Assessment
5. Mobility and Function
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Full range of motion
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Limited range of motion
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Needs assistance with mobility
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No issues with daily activities
6. Mental Health
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Patient is oriented to time, place, and person
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Reports no feelings of anxiety or depression
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Displays signs of stress or emotional distress
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Requires mental health referral
7. Recommendations
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No immediate action required
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Follow-up appointment needed
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Referral to specialist required
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Lifestyle recommendations given
Action Items
List any concerns or follow-up actions.
Clinical Assessment Rating Scale
Rate the patient’s overall health status.
Assessment Form Templates @ Template.net
