Raven EMS Education Program Manual
Clinical Patient Assessment Form

Date: Student name:
Medical record #:
(spot checked for accuracy)		 Gender:
  • Male
  • Female
    		•  Age: (years)
    Chief complaint:
    LOC Airway Breathing Pulse Skin
  • Alert
  • Verbal
  • Pain
  • Unresponsive
    		•
  • Patent
  • Obstructed
    		•
  • Unlabored
  • Labored
  • Absent
  • Shallow
    		•
  • Normal
  • Abnormal
  • Absent
  • Irregular
  • Slow
  • Rapid
    		•
  • Normal
  • Abnormal
  • Cyanotic
  • Diaphoretic
  • Flushed
  • Pale
    		•
  • Moist
  • Dry
  • Cool
  • Warm
    		•
    Eyes Verbal Motor
  • 4-Spontaneous
  • 3-Speech
  • 2-Pain
  • 1-None
    		•
  • 5-Oriented
  • 4-Confused
  • 3-Words
  • 2-Sounds
  • 1-None
    		•
  • 6-Obeys
  • 5-Localized
  • 4-Withdaws
  • 3-Flexion
  • 2-Extension
  • 1-None
    		•
    Time Blood Pressure Pulse Resp SpO2 Pain Comment
    / % /10
    / % /10
    / % /10
    / % /10
    / % /10
    / % /10
    SAMPLE
    Signs/Symptoms:
    Allergies:
    Medications:
    Past medical history:
    Last oral intake:
    Events:
    Treatments
    Narrative
    Student Signature

    Change Log (3.85.188.CPAF)

    DateAuthorDescription of ChangeCitations
    2024-08-27Becker, T.Theron Jack BeckerAdded Clinical Patient Assessment Form.
    2025-01-02Becker, T.Theron Jack BeckerMoved online from Adobe InDesign document.
    Relevant. Resolute. Ready.
    Raven EMS Education Manual - Table of Contents
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