Physical Assessment Form

Name: _______________________
Date: __________________

Vital Signs

1. Temperature: ______ 97.0 – 99.5 Site: __________

2. BP: ______ 120 / 80 Left Arm Right Arm Other: _________ Position:_______
3. Pulse: ______ reg rate reg ryth irreg weak 1+ steady 2+ strong 3+ bounding 4+
4. Resp. Rate: ______ even/reg irreg  labored moderate shallow deep apnea
5. O2 Sat.: ______ 93% - 100%
6. Pain: ______ Location: ______ Description: ____________________________

Special Notes: ___________________________________________________________

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HEENT

1. Eyes
a. Pupils PERRLA equal round raxn to light accom convergence Size:
_____mm

b. Vision  nearsighted farsighted glasses  contacts

2. Ears
a. Hearing aids left ear right ear  none
b. Pain/Wax build up left ear right ear  none
c. Comprehension yes no 
3. Nose
a. Drainage yes no
b. Blockages yes no
c. Sense of Smell yes no
d. Congestion yes no
e. Mucous Membranes moist  pink pale pallor
4. Throat/Mouth
a. Mucous Membranes 
moist pink pale pallor
b. Oral Hygiene  teeth dentures good poor
c. Swallowing  easy difficult painful
d. Lymph nodes normal enlarged

Special Notes: ___________________________________________________________

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Neuro

1. LOC 
alert lethargic obtunded stupor coma
2. Orientation x3  person place time

3. Mood happy depressed anxious angry confused
4. Communication clear/effective unclear/ineffective partial
5. Motor Function steady/strong
 unsteady/weak partial
6. Glasgow Coma Scale
Spontaneous--open with blinking at baseline  4 points
Opens to verbal command, speech, or shout  3 points
Eye Opening Response
Opens to pain, not applied to face  2 points
None  1 point
Oriented  5 points
Confused conversation, able to answer questions  4 points
Verbal Response Inappropriate responses, words discernible  3 points
Incomprehensible speech  2 points
None  1 point
Obeys commands for movement  6 points
Purposeful movement to painful stimulus  5 points
Withdraws from pain  4 points
Motor Response
Abnormal (spastic) flexion, decorticate posture  3 points
Extensor (rigid) response, decerebrate posture  2 points
None  1 point
Total= ______
Special Notes: ___________________________________________________________
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Integument

1. Color pink jaundice

 pallor ashen dusky erythema cyanotic aprop to race
2. Hair Distribution even uneven
3. Moisture  wet 
moist dry clammy
4. Temperature hot warm cool cold
5. Texture 
smooth  rough
6. Turgor ____ seconds
7. Vascularity high normal low
8. Edema 
none 
little yes location: _________________
9. Lesions no yes location: ________________shape: _______________
type: ______________color: _______________
Special Notes: ___________________________________________________________
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Chest/Thoracic

1. Cardiac
a. A/P (S2 “dub”) clearly audible muffled
 
murmur  gallops
b. Erbs Pt clearly audible muffled
 
murmur  gallops
c. T/M (S1 “lub”) clearly audible muffled
 
murmur  gallops
d. Heart Beat regular irregular

e. Apical rate ______
f. Apical Rhythm regular irregular 
g. PMI located yes ___________ no
h. Cap refill ______ seconds brisk rapid sluggish
2. Respiratory
a. Breath Sounds Anterior clear wheezes crackles
Posterior clear wheezes crackles
b. Respiration rate: _____ even reg irreg
 labored shallow deep
c. Chest Expansion symmetrical unsymmetrical

d. Cough no  yes non-productive
 productive color:_________
amount: ___________
e. SOB yes no little difficulty w/ respirations
Special Notes: ___________________________________________________________
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GI/Abdomen

1. Inspection 
flat 
round
2. Bowel Sounds x4 active hyperactive hypoactive faint absent
RLQ active hyperactive hypoactive faint absent
RUQ active hyperactive hypoactive faint absent
LUQ active hyperactive hypoactive faint absent
LLQ active hyperactive hypoactive faint absent
3. Palpation soft hard firm tender
 non-tender distended

4. Diet good
 
average 
poor tube
5. Toleration of diet good average poor 
6. Change in appetite yes no
7. Recent weight change none  gain loss
8. NG/GT tube no yes intact flushed continuous bolus feeds

Special Notes: ________________________________________________________

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Elimination
 1. Urine 
continent incontinent

clear 
cloudy yellow amber bloody tea-colored foul smelling

diapers 
catheter
2. Last BM: _________ how often:___________
brown yellow black tarry green
watery soft
 hard formed diarrhea
Special Notes: ___________________________________________________________
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Musculo-Skeletal

1. ROM 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. Pulses radial 1+ 2+ 3+ 4+ dorsalis pedis 1+ 2+ 3+ 4+
4. Gait steady/balanced
 unsteady/unbalanced limping shuffled
5. Posture straight
 
slumped
6. Ambulates 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. Edema no  yes location: _____________
10. Abnormalities no yes description: _________________________________

Special Notes: ___________________________________________________________

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%IBM/BMI

Height: _____lbs. Weight: ______in. BMI: _______ %IBM: ______%

BMI: weight / (height)² x 705

Less than 18.5 underweight 25.9 – 29.9 overweight
18.5 – 24.9 normal 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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