BROKENSHIRE COLLEGE

Madapo, Davao City

NURSING ASSESSMENT TOOL

I. HEALTH HISTORY

A. Biographical Data

Name of Client:_______________________________________________________________________
Address:_____________________________________________________________________________
Age:______ Date of Birth:__________ Tel. #:______________________
Sex:______ Marital Status:___________________ Occupation:___________________
Source of Information:_______________________
Date and Time History was Taken:_______________________________

B. Chief of complaint(s) Reason(s) for seeking health care:

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C. History of present illness ( if any)

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D. Past medical History

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E. Present health
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F. Past Health History:

Childhood illness:
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Accident / injuries:
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Serious or Chronic disease:
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Hospitalizations:
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Obstetric history:
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Immunizations:
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Last Exam date (Dental, vision, hearing,EKG, Chest Xray):
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Allergies:
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Current Medications:
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Habits:
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Activities of daily living (hygiene and grooming practices; ambulation, self-care, etc)
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Recent travel:
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Family History of illness (attach genogram);
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Personal and social history :
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Family members at home:

Name Age Relationship

Economic history(source of Income livelihood, financial ass.,etc.):

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II. REVIEW OF SYSTEMS

I. Integument (skin, hair, nails)
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II. Head
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III. Eye structures & visual acuity
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IV. Ears and hearing

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V. Nose and sinuses
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VI. Mouth and oropharynx
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VII. Neck
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VIII. Thorax and lungs
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IX. Heart and central vessels
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X. Peripheral vascular system
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XI. Breast and axillae
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XII. Abdomen
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XIII. Musculoskeletal system
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XIV. Neurological system
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XV. Genitals and inguinal area
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XVI. Rectum and anus
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III. PHYSICAL EXAMINATION

I.General appearance and mental status

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II. Vital signs/ measurement

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III. Integument
A. Skin
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b. Hair.
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C. Nails
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IV. Head
A. Skull
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B. Face
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V. Eye structures & visual acuity

A. External eye structures
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C. Visual fields
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D. Extrocular muscle
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E. Visual acuity
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VI. Ears and hearing
a. Auricles
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b. External ear canal and tympanic membrane

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c. Gross hearing and acuity
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VII. Nose and sinuses

a. Nose
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d. Facial sinuses
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VIII. Mouth and oropharynx

A. Lips and buccal mucusa
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F. Teeth and gums
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G. Tongue / floor of the mouth
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H. Salivary glands
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e. Palates and uvula
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f. Oropharynx and tonsils
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IX. Neck
A. Neck muscles
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I. Lamp nodes
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J. Trachea
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K. Thyroid gland
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X. Thorax and lungs

A. Posterior thorax
Inspection
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palpation
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Percussion
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Auscultation
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B. Anterior thorax
Inspection
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Palpation
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Percussion
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Auscultation
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XI. Heart and central vessels

A. Precordium, aortic and pulmonic areas, tricuspid area, apical area, epigastric area
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L. Carotid arteries
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M. Jugular veins
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XII. Peripheral vascular system

A. Peripheral pulses
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N. Peripheral veins
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O. Peripheral percussion
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XIII. Breast and axillae

Inspection
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Palpation
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XIV. Abdomen
Inspection
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Auscultation
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Percussion(including liver)
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Palpation (including liver and bladder)
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XV. Musculoskeletal system

A. Muscles
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P. Bones
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Q. Joints
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XVI. Neurological system

A. Language
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B. orientation
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C. Memory
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D. Attention and circulation
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E. Level of consciousness
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F. Cranial nerves
Cranial nerve I- olfactory
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Cranial nerve II- optic
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Cranial nerve III- oculomotor
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Cranial nerve IV- trochlear

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Cranial nerve V - trigeminal
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Cranial nerve VI- abducens
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Cranial nerve VII- facial
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Cranial nerve VIII- auditory
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Cranial nerve IX- glossopharyngeal
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Cranial nerve X- vagus
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Cranial nerve XI- accessory
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Cranial nerve XII- hypogossal
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G. Reflexes
Biceps reflex
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Triceps reflex
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Brachioradialis reflex
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Patellar reflex
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Achilles reflex
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Plantar (bobinski’s) reflex
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H. Motor function
Gross motor and balance
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Fine motor (upper extremities)
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XVII. Genitals and inguinal area

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XVIII. Rectum and anus

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XIX. Other observations / findings

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Conducted by: _____________________________________
Chief Instructor: ____________________________________ Date: __________________________
Rating: ____________________________________________