This form captures the four elements of the CRB-65 severity assessment: new confusion, respiratory rate ≥ 30 breaths/min, systolic blood pressure < 90 mmHg or diastolic ≤ 60 mmHg, and age ≥ 65 years. Each criterion contributes one point to the score (0–4). The CRB-65 score is widely used in acute and primary care settings to support decision-making when evaluating suspected or confirmed pneumonia. The form provides a structured data entry workflow and generates the total score automatically for documentation and clinical assessment.