Safety Assessment Tool

Subjective (Reports)
Allergies/sensitivity (medications, foods, environment, latex):___________________________________________
__________________________________________________
Type of reaction:_______________________________________________________________________________
Blood transfusion/number:______________ Date:______________ Reaction (describe):______________

Exposure to infectious diseases (e.g., measles, influenza, pink eye):
_____________________________________________________________________________________________
Exposure to pollution, toxins, poisons/pesticides, radiation (describe reactions):
_____________________________________________________________________________________________
Geographic areas lived in/recent travel:
_____________________________________________________________________________________________
Immunization history/date: Tetanus:_______ MMR:_______ Polio:_______ Hepatitis:_______ Pneumonia:_______ Influenza:_______ HPV:_______
Altered/suppressed immune system (list cause):
_____________________________________________________________________________________________
History of sexually transmitted disease (date/type):________________________________ Testing:_________________________________
High-risk behaviors (specify):
_____________________________________________________________________________________________
Uses seat belt regularly:______________ Uses bike helmet:______________ Other safety devices:______________
Work place safety/health issues (describe):_______ Occupation:_______ Currently working:_______ 
Rate working conditions (e.g.,safety, noise, heating, water, ventilation):
_____________________________________________________________________________________________
History of accidental injuries:____________________________ Fractures/dislocations:____________________________
Arthritis/unstable joints:__________________________________________ 
Back problems:__________________________________________
Skin problems (e.g., rashes, lesions, moles, breast lumps, enlarged nodes)/describe:_______________________
_________________________________________
Delayed healing (describe):______________________________________________________________________
_________________________________________
Cognitive limitations (e.g., disorientation, confusion):__________________________________________________
___________________________________________
Sensory limitations (e.g., impaired vision/hearing, detecting heat/cold, taste, smell, touch):__________________
___________________________________________
Prosthesis:____________________________ Ambulatory devices:____________________________
Violence (episodes or tendencies):________________________________________________________________
____________________________

Objective (Exhibits)
Body temperature/method (e.g., oral, rectal, tympanic):_______________________________________________
Skin integrity (mark location on diagram):_______ Scars:_______ Rashes:_______ Lacerations:_______ Ulcerations:_______ Bruises:_______
Blisters:______________ Drainage:______________ Burns (degree/% of body surface):______________

Safety Assessment Tool 

Musculoskeletal: General strength:________ Muscle tone:_________ Gait:________ 
ROM:______ Paresthesia/paralysis:_____
Results of testing (e.g., cultures, immune function, TB, hepatitis):___________________________
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