Davao Doctors College, Inc.

Gen. Malvar St., Davao City

College of Allied Health Sciences | Nursing Program

COMPREHENSIVE HEALTH ASSESSMENT

Name of Patient: __________________________________________ Age: _____ Sex: _____ Civil Status: _________
Impression/ Diagnosis: ____________________________________________________________________________
Date of Admission: ____________________ Attending Physician: _____________________ Room No.: ___________
Date of Assessment: ________________

I.HEALTH HISTORY

Chief Complaint: __________________________________________________________________________________

Present health status:

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Past health history:

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Current Lifestyle:
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Psychosocial status:
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Family history:
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Gynecologic history (if applicable):

Menstrual History (Usual Cycle) Interval: ________ Duration: ________ Amount of Menstrual Flow: _________
Last Menstrual Period and LMP: ______________ EDD: ____________________
Expected Date of Delivery
History of Dysmenorrhea? [ ] Yes [ ] No Gynecologic surgeries? [ ] No [ ] Yes; pls. specify:________

Obstetric history (if applicable):

Pregnancy Profile (GPTAL) Gravity: ___ Term: ___ Preterm: ___ Abortions: ___ Living Children: ____

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 Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program

Previous Pregnancies? [ ] No [ ] Yes; Please specify in chronological order):

Date: Name of Child Type of Delivery Outcome

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II. PHYSICAL EXAMINATION

A. PRELIMINARIES

VITAL SIGNS AND ANTHROPOMETRIC MEASUREMENTS

Blood pressure: _____________________________ Height: _____________________________
Heart rate: _____________________________ Weight: ____________________________
Pulse Rate: _____________________________ BMI: _______________________________
Temperature: _____________________________ [ ] within ideal body weight (IBW)
Respiratory Rate: _____________________________ [ ] less than IBW
Others: _____________________________ [ ] more than IBW; specify:

GENERAL SURVEY:

B. INTEGUMENT
SKIN
Color: ________________________________________________________________________________________
Texture: ________________________________________________________________________________________
Turgor: ________________________________________________________________________________________
Scaling: ________________________________________________________________________________________
Hair Distribution: __________________________________________________________________________________
Hair Characteristics: _______________________________________________________________________________
Infestation: ______________________________________________________________________________________
Comments: ________________________________________________________________________ ______________

STOMA [ ] not Applicable

[ ] clean dry [ ] redness [ ] chronic redness [ ] drainage [ ] chronic drainage [ ] prolapsed

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 Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program

Comments: ______________________________________________________________________________________

FINGERNAILS & TOENAILS

[ ] color, chare, cleanliness good [ ] no problems or deviations assessed
[ ] irregularities in surface: __________________________________________________________________________
[ ] inflammation around nails: ________________________________________________________________________
[ ] fungal problem: _________________________________________________________________________________
C. HEAD AND NECK
HEAD & NECK
Head motion (describe): ___________________________________________________________________________
[ ] asymmetric head position (describe): _______________________________________________________________
[ ] shrugs shoulders [ ] unable to support head midline & erect [ ] dull, puffy, yellow skin
[ ] peritoneal edema [ ] lymph node enlargement [ ] thyroid enlargement [ ] tracheal displacement
Comments: ____________________________________________________________________________ __________

NOSE & SINUSES

[ ] nasal drainage [ ] inflamed [ ] tender [ ] polyps/lesions [ ] edema
[ ] altered nasal mucosa (describe): ___________________________________________________________________
[ ] absence of frontal sinus glow [ ] right nostril occluded [ ] left nostril occluded
Comments: ______________________________________________________________________________________

MOUTH & PHARYNX

[ ] altered oral mucous membrane (describe): ___________________________________________________________
[ ] Inflammation (describe): __________________________________________________________________________
[ ] hoarseness [ ] bruxism (grinds teeth) [ ] loose teeth [ ]decay [ ]halitosis [ ] excessive salivation
[ ] lips dry, cracked [ ] lip fissures [ ] lip bleeding [ ] gums inflamed [ ] gums bleed [ ]gum retraction
[ ] thick tongue [ ] tongue dry, cracked [ ] tongue fissures[ ] tongue bleeds

Inspected the following:

[ ] Inner oral mucosa [ ] buccal mucosa [ ] floor of mouth and tongue [ ]hard palate [ ] soft palate
Deviations (describe): ______________________________________________________________________________
[ ] lesions, vesicles (describe): _______________________________________________________________________
[ ] gag reflex absent [ ] gag reflex hyperactive [ ]poor denture fit or not using [ ] chewing problem [ ] missing teeth
Comments: ______________________________________________________________________________________

D. EYES AND EARS

EYES
Visual acuity: ____________________________________________________________________________________
Visual fields/peripheral: ____________________________________________________________________________
Eye tracking present: [ ] up [ ] down [ ]right [ ] left [ ] corneal light reflex aligned [ ] light reflex misaligned [ ]nystagmus
External eye structure:
Abnormalities (specify/describe): _____________________________________________________________________
Blink reflex: ______________________________________________________________________________________
Pupil & Iris direct light response: _____________________________________________________________________
Pupil & Iris consensual light response: _________________________________________________________________
Ophthalmoscopic exam: ____________________________________________________________________________
Unable to do ophthalmoscope exam due to: ____________________________________________________________
Comments: ______________________________________________________________________________________

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 Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program

EARS
External ear structures: ____________________________________________________________________________
External ear structure abnormalities: __________________________________________________________________
Other abnormalities (describe): ______________________________________________________________________
Otoscopic exam:
[ ] cone of light visualized [ ] cone of light not visualized [ ] tympanic membrane inspected [ ] excessive cerumen
[ ] Unable to examine [ ]Simple hearing acuity test:
Comments: _____________________________________________________________________________________

E. CARDIOPULMONARY
HEART & VASCULAR
Auscultated heart sounds: _________________________________________________________________________
Apical pulse (rate & rhythm): _______________________________________________________________________
Jugular venous distention: [ ] present [ ] absent Capillary refill: [ ] > 1 second [ ] < 2 seconds
[ ] PMI palpable – 5th intercostal space medial to left midclavicular line [ ] PMI not palpable
[ ] edema (describe): _____________________________________________________________________________
Blood Pressure: ________________________________ MAP: _________________ [ ] Pulse Deficit: _____________
Peripheral Pulses: _______________________________________________________________________________
Comments: _____________________________________________________________________________________

THORAX & LUNGS

Inspected: [ ] posterior thorax [ ] lateral thorax [ ] anterior thorax
Thorax deviations: [ ] scoliosis [ ] lordosis [ ]barrel chest [ ] intercostal bulging
[ ] Others: ____________________________________________________________________________________
Auscultated breath sounds:
[ ] vesicular sounds at periphery
[ ] bronchovesicular sounds between scapulae or 1st – 2nd intercoastal space lateral to sternum
[ ] bronchial sounds over trachea
Adventitious sounds: [ ] wheezes [ ] crackles [ ] rhonchi Location: ________________________________________
[ ] clear with cough [ ] Other: _______________________________________________________________________
Respiratory distress: [ ] nasal flaring [ ] use of accessory muscles, specify: __________ [ ] SOB [ ] Intercoastal retraction
Respiratory Rate: _____________Oxygen Saturation: ______________ [ ] apnea, _____________________________
Comments: _____________________________________________________________________________________

F. GASTROINTESTINAL
ABDOMEN
Bowel Sounds: [ ] Present in all quadrants, counts per minute: __________________ [ ] absent:
[ ] hypoactive [ ] hyperactive [ ] tympanic
Abdomen: [ ] flat [ ] distended [ ] soft [ ] firm [ ] rounded [ ] obese [ ] asymmetry
[ ] pain [ ] rebound tenderness [ ] umbilical hernia:
[ ] Others:_________________________________________________________________________
[ ] gastrostomy [ ] jejunostomy [ ] large intestine transverse ostomy
[ ] large intestine sigmoid ostomy
[ ] mass: __________________________________________________________________________
Abdominal Skin Characteristics:______________________________________________________________________
Comments: ______________________________________________________________________________________

G. GENITOURINARY (GYNECOLOGICAL & BREASTS)

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 Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program

BREASTS
Deviations assessed in: [ ] size [ ] symmetrical [ ] contour [ ] shape [ ] skin color [ ] texture [ ] venous pattern
Nipple deviations: [] retraction [] discharge [] bleeding [] nodules [] edema [] ulcerations
Breast self-exam (if applicable): [ ] independent [ ] needs instructions to complete [ ] unable to complete
Comments: ______________________________________________________________________________________
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GENITO-URINARY & GYNECOLOGIC

External genitalia inspected: [ ] excoriations [ ] rash [ ] lesions [ ] vesicles [ ] inflammation [ ] bright red color [ ] swelling
[ ] bulging [ ] discharge [ ] inguinal hernia [ ] tight scrotal skin [ ] large scrotum [ ] phimosis [ ] displaced meatus
Testicular self-exam (if applicable): [] independent [] needs instructions to complete [] unable to complete
Comments: ______________________________________________________________________________________
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OBSTETRIC ASSESSMENT (IF APPLICABLE)

Estimated Fundal Height: ______________ Estimated AOG (based on FH measurement): _______________________
Age of Gestation (AOG): __________________________
Fetal Presentation & Attitude Fetal Line: Fetal Position:
O Cephalic O Longitudinal O Occiput posterior O Occiput anterior
[ ] Vertex [ ] Sinciput [ ] Brow [ ] Face [ ] Chin O Transverse O ROP O LOA
O Shoulder O Oblique O ROT O LOT
[ ] Complete [ ] Footling [] Frank O ROA O LOP
O Breech
[ ] Arm [ ] Shoulder [ ] Trunk
O Compound; specify: ______________________

Uterine Contraction: Fetal Station and Engagement:

Strength [ ] -3
O Mild [ ] -2
O Moderate [ ] -1
O Severe [] 0
[ ] +1
Duration: ________________ [ ] +2
Interval: _________________ [ ] +3
Frequency: _______________

Comments:
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H. MUSCULOSKELETAL

[ ] Gait abnormalities: ______________________________________________________________________________

[ ] Posture abnormalities: ___________________________________________________________________________
[ ] Impaired weight bearing stance: ___________________________________________________________________
[ ] Bilateral symmetry: _____________________________________________________________________________

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 Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program

[ ] Asymmetry: ___________________________________________________________________________________
[ ] Bilateral alignment: ______________________________________________________________________________
[ ] Misalignment: __________________________________________________________________________________
[ ] Decreased ROM: _______________________________________________________________________________
[ ] Joint swelling [ ] stiffness [ ] tenderness [ ] Heat: _______________________________________________________
[ ] Hypertonicity: __________________________________________________________________________________
[ ] Hypotonicity: ___________________________________________________________________________________
Comments: ______________________________________________________________________________________
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I. NEUROLOGIC SYSTEM

MENTAL & EMOTIONAL STATUS

[ ] alert [ ] aware of environment [ ] impaired consciousness GCS score:______ RLS score:________
[ ] changed level of consciousness [ ] unchanged level of consciousness
[ ] able to communicate [ ] vocalizes sounds [ ] limited verbalization [ ] non-verbal
[ ] change in communication pattern [ ]unchanged communication
Communication device: _______________________________________________________________________
[ ] intellectual impairment unchanged [ ] memory impairment unchanged [ ] general knowledge deficit unchanged
[ ] abstract reasoning unchanged [ ] impaired association ability unchanged [ ] impaired judgment unchanged
[ ] changes in mental & emotional status
(describe):________________________________________________________________
Comments:______________________________________________________________________________________
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CRANIAL NERVE (CN) FUNCTION

CN I- olfactory [ ] intact [ ] impaired [ ] unknown
CN's II-II-IV-V- optic, oculomotor, trochlear, abducens (see eye exam)
CN VI – trigeminal (facial sensory & jaw motor) [ ] intact [ ] impaired
CN VII - Facial (symmetry in face expressions & taste) [] intact [] impaired [ ] intact [ ] impaired
CN VIII – Acoustic (see hearing exam)
CN IX- Glossopharyngeal (taste at back of tongue) [ ] intact [ ] impaired
CN X - Vagus (palate movement, "ah" and vocal motor [ ] intact [ ] impaired
CN XI – Spinal Accessory (head motion & shrug) [ ] intact [ ] impaired
CN XII – Hypoglossal (tongue position & motor) [ ] intact [ ] impaired

SENSORY FUNCTION
Touch [ ] intact [ ] impaired (describe): ________________________________________________________________
Pain [ ] intact [ ] impaired (describe): _________________________________________________________________
MOTOR FUNCTION
[ ] impaired coordination [ ] fine motor skills impaired
[ ] balance maintained while standing with eyes closed [ ] loss of balance immediate

REFLEXES
patellar reflex: [ ] 0: no response [ ] 1+ low (normal with slight contraction)
[ ]2+ normal, visible muscle twitch and extension of lower leg
[ ]3+ brisker than normal
[ ]4+ hyperactive, very brisk

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 Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program

SUMMARY OF SIGNIFICANT FINDINGS (Narrative):

NURSING DIAGNOSES
1.
2.
3.

Assessment done by:

Signature over Printed Name of Student

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 Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program

II. FOCUSED PHYSICAL ASSESSMENT [Should be completed on the 2nd and 3rd day]
System Assessed: [ ] Integument [ ] Head & Neck [ ] Eyes & Ears [ ]Cardiopulmonary
[ ] Preliminaries [ ] Gastrointestinal [ ] Genitourinary/OB [ ] Musculoskeletal [ ] Neurologic

Inspection
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Palpation
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Percussion
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Auscultation
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Other significant findings:

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Nursing Diagnosis:
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Assessment done by:

Signature over Printed Name of Student

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