Patient Medical History Checklist

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General

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Are there any signs of excessive wear and damage visually?

Yes No Na

Is the base, framework, bed ends, and side rails in good condition?

Yes No Na

Are the rail welds free of damage and cracks?

Yes No Na

Are there any signs of warping, bending, or damage on foot and head sections?

Yes No Na

Are all rivets and bolts tightened securely and functioning properly?

Yes No Na

Are the surfaces and links intact?

Yes No Na

Do casters roll and lock as required?

Yes No Na

Does the bed lower and raises properly?

Yes No Na

Does the foot lower and raise properly?

Yes No Na

Does the head lower and raise properly?

Yes No Na

Are electrical parts free of excessive wear or damage?

Yes No Na

Are power, pendants, and motor cords free of excessive wear, cuts, or signs of chafing?

Yes No Na

Are all plugs damage-free and fully attached?

Yes No Na

Is the junction box cable lock properly positioned and locked?

Yes No Na

Are all other mechanical functions in working condition?

Yes No Na

Is the mattress cover free from rips or cracks?

Yes No Na

Does the emergency hand crank work properly?

Yes No Na

Are any harsh cleaning agents used to clean the beds?

Yes No Na

Is greasing done periodically to actuators, tubes, pins, etc?

Yes No Na

Are there any signs of impedance or leakage?

Yes No Na

Are damaged parts replaced/repaired as required?

Yes No Na

Are records maintained for cleaning and maintenance?

Yes No Na

Comments

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Inspectors Name/signature:

SIGNATURE

Inspection Date:

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Patient Medical History Checklist

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