Physical Assessment Form

Name: _______________________ ___________________________________

Date: __________________
Vital Signs
1.Temperature:_____________________Site: ______________________
2 . B P 120 / 80)-- Left Arm____
Right Arm_____Other: _________ Position:_______
3 . P u l s e _ _ _ _ _ _ _ reg rate reg ryth irreg weak 1+ steady 2+ strong 3+
bounding 4+
4 . R e s p . R a t e : _ _ _ _ _ even/reg irreg labored moderate shallow deep apnea
5.O2 Sat.: _______________93% - 100%
6.Pain: ________________ Location: ______ Description: ________________
_____
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
___________ ______________________________________________________
_________________ ____ ___________________________________________
_____________________________________________________
HEENT
1. Eyes
a . P u p i l s - PERRLA equal round rxn to light
convergence
Size:
_____mm
b . V i s i o n - nearsighted farsighted
glasses
2. Ears
a.Hearing aids-b. Pain/Wax build up-c.Comprehension --

left ear
left ear
yes

3. Nose
a.Drainage -yes
b.Blockages
-c.Sense of Smell-d.Congestion -yes
e.Mucous Membranes--

accom
contacts lenses

right ear
right ear
no

no
yes
yes

none
none

no
no
no

moist

pink

4. Throat/Mouth
a.Mucous Membranes -moist
pink
pale
b.Oral Hygiene-teeth
dentures good
c.Swallowing -easy
difficult
painful
d.Lymph nodes-normal
enlarged

pale

pallor
pallor
poor

Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
___________ ______________________________________________________
______________________________
Neuro
1 . L O C - alert
2.Orientation3. Mood
confused
4. Communication 5. Motor Function 6.Glasgow Coma Scale
Eye Opening Response

Verbal Response

lethargic obtunded stupor

x3
person
place
happy
depressed anxious

coma
time
angry

clear/ effective unclear/ ineffective

steady/strong
unsteady/weak

partial
partial

Spontaneous--open with blinking at baseline

4pt

Opens to verbal command, speech, or shout

3pts

Opens to pain, not applied to face

2pt

None

1pt

Oriented

5pt

Confused conversation, able to

answer questions
Inappropriate responses, words discernible

4pt

Incomprehensible speech
None

Motor Response

3pt
2pt
1pt

Obeys commands for movement

6pt

Purposeful movement to painful stimulus

5pt

Withdraws from pain

4pt

Abnormal (spastic) flexion, decorticate posture

3pt

Extensor (rigid) response, decerebrate posture

2pt

None

1pt

Total=
____________
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
___________ ______________________________________________________
______________________________
Integument
1 . C o l o r pink/ jaundice /pallor/ ashen/ dusky erythema cyanotic
aprop to race
2.Hair Distribution-even
uneven
3 . M o i s t u r e - wet
moist
dry clammy
4.Temperature-hot
warm
cool
cold

5.Texture -smooth
rough
6.Turgor -____ seconds
7.Vascularity-high
normal
low
8 . E d e m a
- none
little
yes
location: _________________
9 . L e s i o n s - no
yes
location: ______________shape: _____________
type: ______________color:
_______________
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
________________________________________________
_____________________ ____________________________________________
________________________
Chest/Thoracic
1. C a r d i a c
a . A / P
( S 2dub) -- clearly audible
muffled
murmur
gallops
b . E r b s P t - - clearly
audible
muffled
murmur
gallops
c . T / M ( S 1lub)--- clearly
audible
muffled
murmur gallops
d . H e a r t B e a t - regular
irregular
e.Apical rate ___________________
f.Apical Rhythm-regular
irregular
g.PMI located
-yes ___________ no_______________
h . C a p r e f i l l _ _ _ _ _ _ seconds
brisk
rapid
sluggish
2 Respiratory
a.Breath Sounds --

Anterior: clear
wheezes
crackles
Posterior; clear
wheezes
crackles
b . R e s p i r a t i o n rate: _____
even reg irreg
labored
shallow
deep
c . C h e s t E x p a n s i o n - - symmetrical
unsymmetrical
d . C o u g h - no
yes
non-productive
productive color:_________
amount: ___________
.

yes

no

little difficulty w/ respirations

Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
_______
GI/Abdomen
1.Inspection: flat
round
2.Bowel Sounds:
x4 active hyperactive hypoactive faint absent
RLQ :
RUQ :

active
active

hyperactive
hyperactive

hypoactive
hypoactive

faint
faint

absent
absent

LUQ :
LLQ :

active
active

hyperactive
hyperactive

3 . P a l p a t i o n
:
4 . D i e t
:
5.Toleration of diet:
6.Change in appetite:
7.Recent weight change:
8.NG/GT tube:

hypoactive
hypoactive

faint
faint

absent
absent

soft hard firm tender

non-tender
distended
good
average
poor
tube
good
average
poor
yes
no
none
gain
loss
no yes
intact flushed continuous bolus feeds

Special Notes:
________________________________________________________ _________
______________________________________________________________ ___
__________________________________________________________________
__ _______________________________________________________________
__________________________________________________________________
__________________________________________________________________
______________________________________________________
Elimination
1 . U r i n e :

continent

incontinent

clear cloudy

yellow
amber bloody tea-colored foul smelling
diapers
catheter
2.Last BM: _________ how often:___________ brown
yellow
tarry green
watery
soft
hard
formed
diarrhea

black

Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
______
Musculo-Skeletal
1 . R O M : Upper extremities :full partial active passive
assistive
Lower extremities:
full partial active passive
assistive
2.Strength
Upper extremities
1+
2+
3+
4+
Lower extremities
1+ 2+
3+
4+
3 . P u l s e s :
radial :
1+
2+
3+
4+
dorsalis pedis:
1+
2+
3+ 4+
4 . G a i t :
steady/balanced unsteady/unbalanced limping shuffled
5 . P o s t u r e :
straight
slumped
6 . A m b u l a t e s :
w/o assistance w/ assistance
crutches walker
cane
wheelchair

7.History of falls:
no
yes
how often: _______________
8.Ability to perform ADLs:
yes
no
9 . E d e m a :
no
yes
location: _____________
10.Abnormalities:
no
yes
description: _________________________________
Special Notes:
___________________________________________________________ ______
_________________________________________________________________
__________________________________________________________________
_____ ____________________________________________________________
___________ ______________________________________________________
_________________ ________________________________________________
_______________________ _____
%IBM/BMI
Height: __ ___lbs.Weight: ____ _ _in.BMI: _ _ _____ %IBM: ______%
BMI:weight / (height) x 705
Less than 18.5underweight
25.9 29.9overweight
18.5 24.9normal weight
30 or above=
obese
%IBM:

actual weight x 100

Ideal weight

Less than 70%

severly underweight
110 120% :
overweight
90 110%:
adequate weight
more than 120% :
obese
Overall Conclusion:
______________________________________________________ ____________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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