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Physical Assessment

Patient Name: MRN: Date:

Eyes: NSF Physical Findings:
Blurred Vision Yes NO Glasses/Contacts Yes NO (Describe and graph all abnormalities by number on Body Chart)
Near Sighted Far Sighted Astigmatism
Inflammation Yes NO Itching Yes NO 1. Abnormal Color:
Drainage Yes NO Color/Amt:____________________
2. Body Piercing :
3. Bruises:
Ears: NSF 4. Decubitus:
HOH: Yes NO (R) (L) Deaf: Yes NO
Dizziness Yes NO Balance Problems Yes NO 5. Dryness:
Pain Yes NO Drainage Yes NO
6. Incisions:
7. Lacerations:
Nose: NSF 8. Lesions:
Congestion Yes NO Sinus Problems Yes NO
Nosebleeds Yes NO Frequency: _______________________ 9. :Rashes:
Pain Yes NO Drainage: ________________________ 10. Scars:
11. Skin Tear:
Mouth: NSF 12. Tattoos:
Bleeding Gums Yes NO Lesions Yes NO
v Sense of Taste Yes NO 13. Vascular Access:
Dental Hygene Good Fair Poor 14. Other:

Throat/Neck: NSF
Sore Throat Yes NO Hoarseness Yes NO
Swollen Glands Yes NO Lumps Yes NO
Stiffness Yes NO Pain Yes NO

Neurological: NSF
LOC: Alert Confused Sedated Somnolent
Speech: Clear Slurred Aphasic Dysphasia
PEARL Yes NO Grip Equal Yes NO
Cooperative Yes NO ________________________________
Oriented to: Person Place Time

Respiratory: NSF
Dyspnea Yes NO w/ Activity At Rest Retractions
Cough Yes NO non-Productive Productive
Hemoptysis Yes NO Cyanosis Yes NO
Lung Sounds: ____________________________________________

Cardiovascular: NSF Vascular Access:

Heart Rate Reg Irreg Brady Tachy AVF: Mature YES NO
Pulses Equal Bilat, _____________________________________
Location: ______________________Date Placed: __________
Edema – Location: ________________________________________
Pitting None-pitting JVD Yes NO Surgeon: ___________________ Where: _________________
Pain Yes NO ______________________________________
Graft:: Surgical Site Healed YES NO
Location: ______________________Date Placed: __________
Gastrointestinal: NSF Surgeon: ___________________ Where: _________________
Appetite Good Poor Recent Change _________________
Bowel Sounds All Quads ________________________________ Catheter: Dressing Clean & Dry YES NO
Colostomy/Ileostomy Yes NO ________________________
Location: ______________________Date Placed: __________
Pain: ____________________________________________________
Other: Surgeon: ___________________ Where: _________________
Brand: _____________________ Model: ________________
Genitourinary: NSF
Urine production per Day: ___________________________________ Art Vol: ____________________ Ven Vol: _______________
Pain Yes NO Incontinence Yes NO

Assessment performed by: Signature:

PM – IV A-07 pg 1 of 1