PHYSICAL ASSESSMENT SHEET -1-

Equipment needed: s/scope BP cuff Thermometer Pen Light Tongue depressor

Initial Observation: Gait: smooth limp uneven halting Hair: colored limp healthy brittle
Face: expression symmetrical Y/N Lumps on head Y/N __________________________
What brings patient here – chief concern? ____________________________________
____________________________________________ BG_____ SpO2:______RA/not_

Assess: T ____ºF BP____/____ RR ____ HR _____ Pain: Y/N ______________________

LOC: A/A Orient x1 x2 x3 _person/place/time_ (ask 3 questions)

Head: ask about sleep ________________________________________________

Eyes: Glasses/Contacts Y/N Pupils Size ____mm P E R R L A ________________

E O M intact / unequal Symm Y/N Conjunc Pink Red Pale Moist Dry
Has eyebrow hair and lashes? Y/N
Assessment of 6 positions of gaze: equal not equal lazy eye - R L
Assessment of peripheral vision: equal 180º not-equal R_____º L_____º

Nose: Nares _Clear/Drng/FB/__________ Septum _Mdln/Dvd_ Patency _Bilat/Rt/Lt_

Ears: Left _OK/Drng/FB/Red/Hair/Aid_ Right _ OK/Drng/FB/Red/Hair/Aid_

Whisper Test _Nml Both/Nml Rt/Nml Lt_______________________________

Mouth/Throat: Tongue _Midline/Diviate L R_ MucMemb _Pink/Pale_Moist/Dry_

Uvula _Midline/Diviate L R_ Odor _________________________
Tonsils _Y/N_ Removed_____/_____/______ Dentures _Y/N_
Lips: OK Dry/cracked Sores_________________________________
Lungs: deep breaths through open mouth only with pt sitting up (8-12 sites)
Anterior Posterior
RUL: Clear Whez Crkl Rhon RUL: Clear Whez Crkl Rhon
RML: Clear Whez Crkl Rhon RML: Clear Whez Crkl Rhon
RLL: Clear Whez Crkl Rhon RLL: Clear Whez Crkl Rhon

LUL: Clear Whez Crkl Rhon LUL: Clear Whez Crkl Rhon
LLL: Clear Whez Crkl Rhon LLL: Clear Whez Crkl Rhon

Resp Rate:_____RPM Regular Irregular Labored Shallow Deep

Chest Expansion symmetrical not symmetrical

At this point check pt’s hand grasp/muscle strength

Chest: lay pt back down to listen to heart (all 5 locations: A, P, E, T, M)

Ask about breathing, SOB, Smoker _Y/N_ Quit_____/_____/_____ P/D #_____
Scars/Tatoos ___________________________________________________
Implants _Y/N_ Pacemaker _Y/N_ Skin Turgor __________________________
PHYSICAL ASSESSMENT SHEET (cont’d) -2-

Cap Refill LUExt _-3/+3_ RUExt _-3/+3_

Apical Pulse _____BPM_ Regular/Irregular Strong/Weak

Radial Pulses: Rt +0 +1 +2 +3 +4 Not Palpable Lt +0 +1 +2 +3 +4 Not Palpable

Abdomen:Ask about dietary habits, how much, how often, preferred foods, etc
Inspection: _flat round scars____________________________________
Bowel Sounds: assess in clockwise manner
RUQ: active hyperactive hypoactive absent
LUQ: active hyperactive hypoactive absent
LLQ: active hyperactive hypoactive absent
RLQ: active hyperactive hypoactive absent

Palpation: soft hard distended Painful: RUQ LUQ LLQ RLQ

Stretch Marks: _____________________________________________________
Percuss: gastric bubble: Y/N

Legs: appearance (rash, bruise, abrasion, edema)___________________________________

_______________________________________________________________________
Left pink pale warm cold dry moist Right: pink pale warm cold dry moist

Pedal Pulses: Lt +0 +1 +2 +3 +4 Not Palpable Rt +0 +1 +2 +3 +4 Not Palpable

Cap Refill LLExt _-3/+3_ RLExt_-3/+3_ Pulse checked w/Doppler if +0? Y/N

Foot strength: equal up equal down unequal up unequal down

Edema: Left leg: Brawny (warm/cold) +1 +2 +3 +4 ____________________________

Right leg: Brawny (warm/cold) +1 +2 +3 +4 ____________________________

Color: _________________________________________________________________

Odor: _________________________________________________________________

C_____________________________________________________________________

A_____________________________________________________________________

Ask pt again if they are in any discomfort now that the assessment is complete.