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Physical Assessment Form Name: _______________________ Date: __________________

Vital Signs
1 T e m p e r a t u r e : _ _ _ _ _ _ (97.0 - 99.5)Site: __________ 2 B P : reg rate _ _ _ _ _ _ reg ryth (120/80)Left Arm Right Arm Other: _________ Position:_______ irreg weak 1+ even/reg steady 2+ irreg strong 3+ bounding 4+ shallow deep apnea 3 P u l s e : _ _ _ _ _ _ (12 - 20) 4Resp.Rate: _____ labored moderate

5 O2Sat.: ______ (93% - 100%) 6 Pain: ______ Locat ion: ______ Descript ion: ____________________________ HEENT1 . 1.Eyes a . P u p i l s PERRLA equal b . V i s i o n 2. Ears a.Hearing aids left ear yes right ear no none none b.Pa in/Wax bu ild up c.Comprehension 3. Nose a . D r a i n a g e b.Blockages d.Congest io n yes yes yes no no yes no moist pink pale pallor no left ear right ear nearsighted round raxn to light farsighted glasses accom contacts convergence Size: _____mm

c.Sense of Smell

e.Mucous Membranes 4. Throat/Mouth a.Mucous Membranes b.Oral Hygiene c.Swallowing d.Lymph no des teeth easy normal

moist dentures difficult

pink

pale

pallor poor

good painful

enlarged