Post-Surgical Home Care Assessment
Patient Information
Name
Date of Birth
Surgery Date
Type of Procedure
General Condition
Vital Signs (BP, HR, Temp)
Pain Level (0-10)
Mobility Status
Wound Assessment
Wound Location
Appearance
Dressing Type
Signs of Infection
Medication Management
Current Medications
Activities of Daily Living (ADLs)
Bathing
Dressing
Toileting
Nutrition
Additional Notes