Website
Patient Name
*
Patient ID
*
Age
*
Gender
Male
Female
Diagnosis / Medical Condition
Doctor Name
Date
Nurse/Attendant Name
Temperature (°F)
Pulse Rate (BPM)
Blood Pressure (mmHg)
Respiratory Rate (Breaths/Min)
Oxygen Saturation (SpO2 %)
Weight (Kg) (if required)
Fasting Blood Sugar
Random Blood Sugar
Post Prandial (PP)
Pain Scale (0-10)
1
2
3
4
5
6
7
8
9
10
Pain Location
Conscious
Yes
No
Alert
Consciousness & Orientation
Yes
No
Oriented to Time
Consciousness & Orientation
Yes
No
Oriented to Place
Consciousness & Orientation
Yes
No
Oriented to Person
Consciousness & Orientation
Yes
No
Walking Independently
Mobility Status
Yes
No
Assisted Walking
Mobility Status
Yes
No
Bedridden
Mobility Status
Yes
No
Fall Risk
Mobility Status
Low
Medium
High
Fluid Intake
Intake & Output
Normal
Reduced
Excessive
Food Intake
Good
Moderate
Poor
Urine Output
Normal
Reduced
Increased
Bowel Movement
Normal
Constipation
Loose Stool
Breathlessness
None
Mild
Moderate
Severe
Cough
Yes
No
Sputum
Yes
No
Oxygen Support
Yes
No
Skin Intact
Yes
No
Pressure Sore Present
Yes
No
Wound Present
Yes
No
Dressing Done
Yes
No
Medication Compliance
All Medicines Taken
Missed Dose
Refused Medication
Adverse Reaction Observed
Red Flag Alerts (Immediate Doctor Notification)
Fever > 100°F
BP > 180/110 or < 90/60
Pulse > 120 or < 50
SpO2 < 92%
Blood Sugar > 300 or < 70
Sudden Confusion
Chest Pain
Severe Breathlessness
Fall Incident
Seizure
Any Other Emergency
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