Circulation Assessment Tool

Subjective (Reports)

History of/treatment date:________High blood pressure:________ Brain injury:________ Stroke:________ 
Heart condition/surgery:________ Rheumatic fever:________
Palpitations:________Syncope:________ Pain in legs:________ Ankle/leg edema:________ 
Blood clots:________ Bleeding tendencies:________
Spinal cord injury/dysreflexia episodes (describe):____________________________________________________
Slow/delayed healing (describe):____________________________________________________________________________________
Extremities: Numbness (location):________________Tingling (location):________________
Cough (describe)/hemoptysis:_________________________________________________________
Change in frequency/amount of urine:________________________________________________________________________________________
Medications/herbals:____________________________________________________________________________

Objective (Exhibits)
Color (e.g., pale, cyanotic, jaundiced, mottled, ruddy):________ Skin:________ Mucous membranes:__________ Lips: Nailbeds:________
Conjunctiva:___________________________________________________________________________________
Skin moisture (e.g., dry, diaphoretic):______________________________________________________________
BP (R & L): Lying:________ Sitting:________ Standing:________ Pulse pressure:________ 
Auscultatory gap:________
Pulses (palpated 1–4 strength):________ Carotid:________ Temporal:________ Jugular:________ Radial:________ Femoral:________ Popliteal:________
Posttibial:_________________________________________________________ 
Dorsalis pedis:_____________________________________________________
Cardiac (palpation): Thrill:_________________________________________________________ Heaves:_______________________________________________________________________
Heart sounds (auscultation):___________ Rate:___________ Rhythm:__________ Quality:__________ 
Friction rub:__________
Murmur (describe location/sounds):___________________________________________________________
Vascular bruit (location):____________________________________________ 
Jugular vein distention:______________________________________________
Breath sounds (describe location & sounds):________________________________________________________
Extremities:________ Temperature:________ Color:________ Capillary refill (1–3 sec):________ 
Edema (+1 to +4):________ Homans sign (+ or –):________
Varicosities (location):________ Nail abnormalities:________ Distribution/quality of hair:________ 
Trophic skin changes:________