BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

PHYSICAL ASSESSMENT CHECKLIST

Name of Patient: _______________________ Name of Student: _______________________

Date of Assessment: _________________________ : _______________________

I. Personal Data
Age: _____________ Sex: ___________
Last Menstrual Period: ____________________

II. Vital Signs

A. Temperature: ______ Site: _________________
B. Pulse: ______ Site: _________________
C. Resp. Rate: ______
D. Blood Pressure: ______ Site: _________________

III. General
A. Body Built Proportionate Ectomorph Mesomorph Endomorph
B. Height _____feet _____ inches
C. Weight __________ kilograms
D. BMI _________________________________
E. Posture Straight Kyphosis Lordosis Scoliosis
F. Gait Balanced Unbalanced Limping Shuffled
G. Hygiene Well kept Tidy Ungroomed Untidy
H. Mental Status Alert Lethargic Obtunded Stupor Coma
I. Mood Pleasant Irritable Calm Happy Anxious
Fearful
J. Affect Surprise Anger Sadness Joy Disgust
Fear Flat
K. Communication Clear Unclear Effective Ineffective Aphasia

IV. Integument
A. Color Pink Jaundice Pallor Erythema Aprop To Race
Cyanotic Melasma Linea Nigra Striae Café’ au lait spots
B. Moisture Wet Moist Dry Clammy
C. Temperature Hot Warm Cool Cold
D. Texture Smooth Rough
E. Turgor ____ seconds Good Poor
F. Hair Distribution Even Uneven
G. Hair Texture Dry Oily Shiny Dull
H. Edema None Little Yes Location: _________________
I. Lesions No Yes Location: _____________________________
Shape: _____________ Size: _____________
Type: ______________Color: _____________
J. Nails Clubbing Pink Cyanotic
K. Capillary Refill ____ seconds Brisk Sluggish Rapid

V. Eyes
A. General Strabismus Doll’s Eye
B. Pupils: Size: _____Mm Equal Round Raxn To Light Accom
C. Iris: Color_______ Pink Opaque Sun Setting
D. Conjunctiva Clear Erythema
E. Sclera Clear Jaundice Blue
F. Cornea Clear Opaque Erythema
G. Vision Nearsighted Farsighted Glasses Contacts
 H. Blink Reflex Yes No

VI. Ears
A. Position of ears Normal Low Set Ears High Set Ears
B. Pain Left Ear Right Ear None
C. Wax Build Up Left Ear Right Ear None
D. Hearing Acuity Left Ear Audible Not-audible
Right Ear Audible Not-audible
E. Watch Tick Test Left Ear Audible Not-audible
Right Ear Audible Not-audible
F. Hearing Aid Left Ear Right Ear

VII. Nose
A. Mucosa Pink Pallor Erythema
B. Drainage Yes No
C. Blockages Yes No
D. Sense of Smell Yes No
E. Flaring Yes No
F. Congestion Yes No
G. Mucous Membranes Moist Pink Pallor Erythema

VIII. Mouth and Throat

A. Mucous Membranes Pink Pallor Erythema Jaundice
B. Tongue Shape Symmetric Asymmetric
C. Tongue Movement Symmetric Asymmetric Freely Movable Protruding
D. Saliva Amount Normal Scanty Excessive
E. Teeth Number ____________ Missing _______________
F. Teeth Condition Intact Dental Caries Dentures
G. Gums Intact Erythema Inflammed
H. Palate Intact Cleft Over arched
I. Tonsils Pink Exudates Grade 1 Grade 2 Grade 3 Grade 4
J. Gag Reflex Yes No
K. Swallowing Easy Difficult Painful
L. Lymph Nodes Normal Enlarged

IX. Chest
A. Breast Round Symmetric Asymmetric Supple Striae
Engorged Tender Irregular Shape Dimpling Pigskin
B. Nipple Left Everted Inverted
Right Everted Inverted
C. Discharge Left Yes No
Right Yes No
D. Areola Round Oval Irregular Shape
Pink Light Brown Dark Brown
E. AP/T Diameter 1:2 Symmetric Asymmetric
F. Vocal Fremitus Anterior Symmetric Asymmetric
Posterior Symmetric Asymmetric
G. Breath Sounds Clear Brochial Vesicular Broncho-vesicular
Wheezes Crackles Rhonchi Friction Rub
H. Respiration Even/Regular Irregular Labored Shallow Deep
Apnea Abdominal/Diaphragmatic
I. Chest Expansion Symmetrical Asymmetrical Retraction
J. Cough No Yes Productive Non-Productive
Sputum Color:_________ Amount: ___________
K. SOB Yes No Little Difficulty W/ Respirations

X. Cardiovascular
A. Heart Sounds S2 “Dub” Clearly Audible Muffled Murmur
S1 “Lub” Clearly Audible Muffled Murmur
 B. Heart Beat Regular Irregular Skip beats
C. Apical Rate ______
D. Apical Rhythm Regular Irregular Bounding
E. Jugular Veins Not Visible Visible
F. Peripheral Pulse Symmetric Asymmetric

XI. Abdomen
A. Shape Flat Round Symmetric Asymmetric
B. Abdominal Girth __________ inches
C. Quickening Yes No
D. Ballottement Yes No
E. Bowel Sounds Quadrant 1 Quadrant 2 Quadrant 3 Quadrant 4
Active Active Active Active
Hyperactive Hyperactive Hyperactive Hyperactive
Hypoactive Hypoactive Hypoactive Hypoactive
Faint Faint Faint Faint
Absent Absent Absent Absent
F. Palpation Soft Hard Firm
Non-Tender Distended Tender
G. Diet Breastfeeding Formula Feeding Mixed Feeding Solid Foods
H. Toleration Of Diet Good Average Poor
I. Change In Appetite Yes No
J. Recent Weight Change None Gain Loss

XII. Musculoskeletal
A. ROM
Upper Extremities Full Partial Active Passive Assistive
Lower Extremities Full Partial Active Passive Assistive

B. Assistive Devices Cane Crutch Walker Wheelchair

C. Deformities None Yes (specify) __________________
D. Amputation None Yes (specify) __________________