Free Clinical Assessment Form Template

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Free Clinical Assessment Form Template

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

        • Male

        • Female

        Phone Number

          Email

            Assessment Checklist

            1. General Health

              • Patient appears well and alert

              • No signs of distress

              • Vital signs are within normal range

              Reported symptoms

                2. Medical History

                  • No known chronic conditions

                  • Known conditions

                  Known Conditions

                  List the known conditions.

                    Current Medications

                    List the current medications.

                      Allergies (if applicable)

                        3. Physical Examination

                          • Skin is clear, no rashes or lesions

                          • Eyes, ears, nose, and throat appear normal

                          • Heart and lungs sound normal

                          Other findings

                            4. Pain Assessment

                              5. Mobility and Function

                                • Full range of motion

                                • Limited range of motion

                                • Needs assistance with mobility

                                • No issues with daily activities

                                6. Mental Health

                                  • Patient is oriented to time, place, and person

                                  • Reports no feelings of anxiety or depression

                                  • Displays signs of stress or emotional distress

                                  • Requires mental health referral

                                  7. Recommendations

                                    • No immediate action required

                                    • Follow-up appointment needed

                                    • Referral to specialist required

                                    • 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