PHYSICAL ASSESSMENT GUIDE

NEUROPSYCHOLOGICAL

MENTAL STATUS: o Oriented o Person o Place o Time o Date o Alert o Dull Affect

SPEECH o Clear o Other_______________

STIMULUS RESPONSE: o Verbal o Touch o Pain

ENT 1

BEHAVIOR: o Cooperative o Uncooperative o Combative o Anxious o Depressed o Restless o Unresponsive o Confused (explain)___________ o Other (explain)______________ GENERAL: o Syncope o Dizziness o Malaise o Seizures o Memory loss o Insomnia o Other______________________ COMMENTS: ENT 2 .

HEAD/NECK: o Symmetrical o Range of motion o Oral mucosa o Pink o Other_______________ o Moist o Dry o Teeth present condition___ o Teeth absent____________ EYES: o Drainage o Pupils o Equal o Unequal o React to light o Accommodate o Sclera o White ENT 3 .

o Jaundice o Other___________________ o Conjunctiva o Pink o Pale o Other___________________ EARS: o Drainage COMMENTS: MUSCULOSKELETAL: o Symmetrical muscles o Full ROM o Absence of joint swelling o Full muscle strength o Steady gait o Other______________________ COMMENTS: RESPIRATORY: Rate_______________ o Effort ENT 4 .

o Norma. o Shallow o Hyperpnea o Wheezing o Dyspnea o Apneic periods o Orthopnea o Labored o Painful o Other______________ o Rhythm o Regular o Irregular o Sounds o Equal o Clear o Other COMMENTS: CARDIOVASCULAR: o Apical pulse ENT 5 .

o Regular o Irregular o Rate______________ o Jugular Neck Distention o Pain PERIPHERAL VASCULAR: o Pulses RT LT o Carotid_____________ o Radial______________ o Brachial____________ o Femoral____________ o Popliteal____________ o Posterior tibial_______ o Dorsalis pedis________ o Rhythm o Regular o Irregular o Homan’s o Pain o Blood pressure ENT 6 .

o Right arm o Left arm COMMENTS: GASTROINTESTINAL: o Abdomen o Soft o Distended o Painful o Rigid o Other_________________ o Bowel sounds o URQ o LLQ o LLQ o RLQ o Intake/Appetite o Percentage____________ o Dysphagia o Trouble chewing o Nausea ENT 7 .

o Vomiting o Weight loss o Weight gain o Other_________________ Food Intolerances: BOWEL HABITS: o Frequency____________________ o Diarrhea o Constipation o Date last BM__________________ o Aids for elimination____________ o Color o Black o Bloody o Other________________ COMMENTS: RENAL/UROLOGICAL: o Urine flow ENT 8 .

o No problems o Urgency o Incontinent o Burning o Hesitancy o Dysuria o Hematuria o Frequency o Other_________________ o Appearance/color_______________ COMMENTS: INTEGUMENTARY: o Coloring o Skin o Pink o Cyanotic o Jaundice o Other_________________ o Texture/Turgor o Dry ENT 9 .

o Moist o Inelastic o Other_________________ o Nail beds o Pink o Pale o Cyanotic o Capillary blanching__sec o Edema o Absent o Pedal o Sacral COMMENTS ENT 10 .

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