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Head to Toe Assessment

VS: (13)
Full set of VS (pulse, Be sure to include where temp was taken from!
resp rate, BP, Temp,
O2 sat)
Pain: Level,
COLDERR (character,
onset, location,
exacerbation, relief,

Neuro: (10)
LOC (Level of
Consciousness) and

Pupils (PERRLA-
Pupils are Equal,
Round, Reactive to
light, and
Sensation (Any
numbness or
Neuro movement Could grasp fingers, push up and down against resistance,
plantar flexion and extension against resistance

Speech Verbal, articulate, no slurring of words or nonsensical speech

CV: (10)
Heart Sounds S1 and S2 clear on aortic, pulmonic, Erb’s point, tricuspid, and
(Diaphragm and Bell) mitral on diaphragm and bell

Cap Refill UE and LE refilled w/I 3 seconds

Edema No edema visible or palpable

Dorsalis Pedis 2+ bilateral

Post Tibial 2+ bilateral

Calf tenderness None reported

Resp: (10)

Inspection No abnormalities found

Breath Sounds Clear, no abnormal breath sounds on posterior or anterior

Resp Effort None noticed or reported by pt.

Cough None reported

Sputum None reported

GI: (10)
Abdomen (soft, round, Soft, round, non-tender
non-tender would be
baseline normal)
Bowel Sounds Active in all four quadrants

Flatus Normal amount for pt., not interfering with daily life

Nausea/Emesis None reported

Stools (Last BM, color,

consistency, amnt)

GU/Renal: (5)
Voiding patterns

Urine characteristics
(Color, clarity,
amount, odor)

Integ/Skin: (7)
Skin Warm and dry to the touch, color appropriate for race and

Heels R/L Bilaterally intact

Scars/Wounds/Incisio One mole on neck