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Burn Evaluation Sheet

The Burn Evaluation Sheet is in a "Portable Document File" (PDF). To view a PDF, you need to have Adobe Acrobat Reader on your computer. If you don't already have Acrobat Reader, you can download it for free. Click here to download your free Acrobat Reader now.

To download a Burn Evaluation Sheet in PDF format, click here.

Check the ABCs first

Name__________________________________Age_________

Date __________________ Time of Burn __________________

Mechanism of injury ______________________Weight_______

Medications_________________________________________

Allergies___________________Tetanus Immunization Status____

Severity of Burn
= 2 degree

= 3 degree

_______ % burn surface area (BSA)

Rule of the palm for small burns: The patient's palm, excluding the digits, is approximately 1 percent body surface area.

Referral Criteria for Transfer to a Burn Center
  • 2 and 3 degree burns >10% Burn Surface Area (BSA)
  • 3 degree burns > 2% BSA
  • Burns that involve the face, hands, feet, perineum and major joints
  • Electrical, chemical and inhalation injuries
  • Circumferential burns of an extremity or chest
  • Burns involving trauma
  • Patients with a burn and a complicating medical disorder
Age in Years
0-1 1-4 5-9 10-14 Adult
A- 1/2 OF HEAD 9 1/2 8 1/2 6 1/2 5 1/2 3 1/2
B - 1/2 OF ONE THIGH 2 3/4 3 1/4 4 4 1/4 4 3/4
C - 1/2 OF ONE LEG 2 1/2 2 1/2 2 3/4 3 3 1/2


 
 
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