Personal Data

Name :___________________________ Age:___

Address:__________________________ Sex:___
Birthday:__________________________

Anthropometric Measurements

Height : Mid Arm Circumference:

Weight : Head Circumference:

Immunization Record (Please Check)

Immunizations Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6

BCG
DPT/DT
MMR
Hib
HEP
PCV
Other Immunizations Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Dose 6

Health History
(Check the appropriate table box and answer the description box for specific types/condition)

Health Problems Yes No Description

Allergies
Anemia
Asthma
Diabetes
Heart Condition
Kidney Disorders
Obesity
Vision Disorders
Attention/Learning Disorders

Allow the Client to answer if possible

Right Handed Left Handed Ambidextrous
My name is ___________________________, they call me___________________, I’m from___________ and my grade level
is_________________, I am best at________________ and my hobbies are____________________, My favorite color
is__________________ and
My favorite food is________________________, My best friend is__________________

General Survey

Vital Signs
Temperature:
Pulse rate:
Respiratory rate:
Pain:

Skin Assessment
Skin Color:________________________
Skin Turgor:_______________________
Capillary Refill:_____________________

Skin Lesions Type of Lesion Location

Primary Lesions

Secondary Lesions

Vascular Lesions

Body Type (Check the Box)

Body Mass Index: ______________

Posture (Check the Box)

Head to Toe Assessment

Skull
Diameter in cm _________
Symmetrical Asymmetrical

Hair and Scalp

Color:______________
Distribution:_________

Scalp condition
Dandruff Lesions Infestations Others:___________

EYES
Color of Iris:__________
Color of Sclera:________
Visual Acuity: ________ Distant , _________Near
Conjunctiva:__________________

Pupils Shape: _________

Reaction to Light: constrict fixed/Dilated
Accommodation: Converges inward Converges outward/asymmetrical
Ability to distinguished colors: Yes No

Eye disorders:____________________

Ears
Outer ear:_______________________________
Presence of pierced lobe earrings: Yes No

Otoscopy: Impacted Cerumen Fungi

Otitis Media Others:__________________
Perforations
Please encircle the findings
Ballpen Click test AC > BC BC < AC
Romberg’s Test Good Balance Poor Balance

Teeth Assessment (Mark X on the missing tooth)

Please encircle the findings

Lips Pinkish Pale Reddish Cyanotic Others:

Gums Pinkish Pale Reddish Discharges Others:
Tonsils +0 +1 +2 +3 +4
Ability to swallow Good Poor Others:
Ability to Identify flavor Sweet Sour Salty Bitter Umami
Other Abnormal Findings: ______________________________________________________________

Heart and Lungs Assessment

Heart Rate:_____________
Heart Sound:____________
Heart defects:___________
Lungs sounds
Right lung ___________
Left lung ____________
Presence of Respiratory conditions:________________________

Abdominal Assessment
Abdominal Girth:____________
Bowel Clicks:_______________
Difficulty in Defecating: Yes No
Stool characteristic:__________
Any Digestion Disorder:________________

UPPER AND LOWER EXTREMITIES

Range of Motion

Body Part Normal ROM Actual Presence of Pain/Stiffness

Neck 6
Shoulders 6
Elbow 2
Wrist 4
Fingers 2
Hip 6
Knees 2
Ankles 4
Toes 2

Physical Deformities (Shade the body part with the deformities)

Deep Tendon Reflexes (Encircle the “+”)

Assessed by:
_____________________________
Student Nurse