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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

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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