Emergency Room Triage Assessment Form
Patient Name
Date of Birth
Gender
Female
Male
Other
Date & Time of Arrival
Mode of Arrival
Walk-in
Ambulance
Other
Chief Complaint
Temperature (°C)
Pulse (bpm)
Respiratory Rate (bpm)
Blood Pressure (mmHg)
Oxygen Saturation (%)
Pain Scale (0-10)
Allergies
Medical History
Triage Category
Red (Immediate)
Orange (Very Urgent)
Yellow (Urgent)
Green (Standard)
Blue (Non-Urgent)
Assessment Notes
Assessment By
Date & Time of Assessment