Title Page

  • Reference #

  • Location
  • Conducted by

  • Conducted on

Equipment and Documents


  • The following are recommended:

  • Bandage scissors

  • Cell phone

  • Cerumen spoons

  • Gauze/tape/packing

  • Gloves (sterile and nonsterile)

  • Glucometer

  • Lubricant

  • Maps or global positioning system (GPS)

  • Otoscope/ophthalmoscope

  • Phlebotomy equipment

  • Sharps container

  • Sphygmomanometer (variety of sizes)

  • Sterile specimen cups

  • Stethoscope

  • Tape measure

  • Thermometer

  • Tongue depressors

  • Tuning fork

  • The following are optional:

  • Computer (portable printer and fax, wireless card, electronic health record)

  • Dictaphone

  • Externally worn hearing amplifier

  • Personal digital assistant (PDA)

  • Portable electrocardiograph

  • Pulse oximeter

  • Vaccines (properly stored)

Patient-supplied (as needed)

  • Glucometer

  • Home blood pressure monitor

  • Nebulizer

  • Peak flow meter

  • Scale


  • “Advance packet” (names, phone numbers, policies, scope of services, questionnaires and patient forms)

  • Assessment tools (e.g., Mini-Mental State Examination, Geriatric Depression Scale, Screen for Caregiver Burden)

  • Billing documentation

  • Business cards/appointment cards

  • Patient record

  • Phonebook of essential community numbers and services

  • Prescription pad


  • Comments/Recommendations

  • Conducted by: Name & Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.