7) Hearing function : ( ) Normal ( ) Less

( ) Deaf, right/left
………………………………………..

8) Balance disorders : ( ) Yes ( ) No

9) Use of tools : ( ) Yes ( ) No

d. Speech Systems : ( ) Yes ( ) No

( ) Aphaisa ( ) Aphonia

( ) Dysartria ( ) Dysphasia ( ) Anarthia

e. Respiratory System

1) Airway : ( ) Clean ( ) There is a blockage; ………….

2) Breathing : ( ) Not overcrowded ( ) Crowded
3) Using accessory muscle of respiration : ( ) Yes ( ) No
4) Frequency : ……………………… x/minute
5) Rhythm : ( ) Regular ( ) Irregular
6) Type of breathing : ( Spontaneous, Kausmaull, Cheynestoke,
Biot, dll )
7) Depth : ( ) Deep ( ) Shallow
8) Cough : ( ) No ( ) Yes …………….. ( Productive/not
productive )
9) Sputum : ( ) No ( ) Yes……………… (
White/yellow/green )
10) Consistency : ( ) Thick ( ) Dilute
11) Blood Found : ( ) Yes ( ) No
12) Chest Palpation :…………………………………………………
13) Chest Percussion :………………………………………………..
14) Breath Sounds : ( ) Vesicular ( ) Ronki

( ) Wheezing ( ) Rales

15) Pain During Breathing : ( ) Yes ( ) No

16) Use of Accessory Muscle : ( ) No ( ) Yes

17) Use of O2 : ( ) Nasal kanule = ………. l/minute

( ) Mask =………...l/minute

f. Cardiovascular System

1) Peripher Circulation
a) Pulse………x/minute : Rhythm : ( ) Regular ( ) Irregular

Pulse : ( ) Weak ( ) Strong

b) Blood Pressure :……………….mm/Hg

c) Jugular venous distention : Right : ( ) Yes ( )No

Left : ( ) Yes ( ) No