Free Medical Assessment Sheet

I. Patient Information

The Medical Assessment Sheet begins with basic patient details. This information is essential for identifying and tracking the patient.

• Full Name: Jake Willms

• Date of Birth: July 15, 1990

• Gender: Male

• Address: Arlington, TX 76001

• Phone Number: 222 555 7777

• Email Address: jake@you.mail

• Emergency Contact: Amelia Pagac, 222 555 7777

• Insurance Provider: HealthFirst Insurance

II. Medical History

• Current Medical Conditions:

  • Hypertension

  • Type 2 Diabetes

• Past Surgeries:

  • Appendectomy, March 12, 2015

• Known Allergies:

  • Penicillin

  • Pollen

• Family History:

  • Father: Heart Disease

  • Mother: Breast Cancer (Remission)

III. Current Medications

List of medications the patient is currently taking to manage health conditions.

IV. Initial Patient Evaluation

• Chief Complaints:

  • Frequent headaches

  • Occasional dizziness

• Symptoms Noted:

  • Fatigue

  • Mild shortness of breath after exercise

• Physical Exam Findings:

  • Blood Pressure: 140/90 mmHg

  • Pulse Rate: 82 beats per minute

  • Temperature: 98.6°F

V. Pre-Surgery Assessment

Before a scheduled procedure, the patient’s overall health and readiness for surgery are assessed in this section.

• Procedure Scheduled: Knee Replacement Surgery

• Scheduled Date: February 15, 2050

• Pre-Operative Tests Completed:

  • Blood work: Normal

  • Chest X-ray: Clear

  • ECG: Normal

• Surgeon: Dr. Lance Nader

• Anesthesiologist: Dr. Jackie Tillman

VI. Follow-Up Appointments

A record of any subsequent visits for follow-up care after treatment or surgery. This ensures proper healing and addresses any concerns post-procedure.

VII. Emergency Room (ER) Triage

• Date of Visit: May 20, 2050

• Reason for Visit: Severe chest pain and shortness of breath

• Vital Signs:

  • Blood Pressure: 150/95 mmHg

  • Heart Rate: 120 beats per minute

  • Oxygen Saturation: 95%

• Initial Diagnosis: Possible heart attack

• Immediate Care Plan: Administer oxygen, IV fluids, and prepare for an EKG

VIII. Insurance and Claims Processing

• Insurance Claim Number: 234567891

• Date of Service: January 05, 2050

• Procedure: Routine Check-up

• Claim Status: Pending approval

Prepared by: [YOUR NAME]
[YOUR EMAIL]

Sheet Templates @ Template.net