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Physical assessment form
- 1. Health Assessment
John Knowles 20F
HEALTH HISTORY – Biographical data, reason for care, health history, family history, special considerations.
MENTAL STATUS – Appearance, behavior, LOC, cognition, though processes.
GENERAL SURVEY – Mobility, physical appearance, body structure.
VITALS
Height/Weight O2 Sat. TPR B/P Current Pain Target Pain
/ % / / / /10 /10
HEAD NECK
Skin/Symmetry of facial features Skin
Hair/Scalp Trachea
CN 7 – motor/CN 5 – sensory Mastoid Process
Temporal pulses Carotid Pulses
Eyes – PERRLA/FOV Carotid Bruits
Ear ROM
Nose
Oral/Dental
ANTERIOR THORAX POSTERIOR THORAX
Skin Skin
Even chest expansion - visual Even chest expansion - palpation
Turgor 10 point breath sounds
8 point breath sounds Breath rate/rhythm/quality
Breath rate/rhythm/quality
Aortic/Pulmonic/Erbs/Tricuspid
60 second Apical heart rate
Heart rate/rhythm/quality
ARMS/HANDS ABDOMEN
Skin Skin
Radial pulses 4 Quadrant bowel sounds
Nails 4 Quadrant palpation
Capillary refill Questions: last bowel
Strength/Resistance movement/diarrhea/constipation/
ROM pain/tenderness
GENITOURINARY LEGS/FEET
Skin Skin/Edema
Palpate bladder Pedal pulses
Questions: pain/urinary problems Nails
Capillary refill
Strength/Resistance
ROM