Patient Name: Date of Admission:

Room no: Chief complaint:

Age/Sex: Occupation:
Weight/Height: S/O:
Address: Marital Status:
Pt receives:
Family Hx Contraptions:
- DM
- Hypertension
- Heart Disease
- Asthma

Current/Previous Disease: Input:

__Injury Output:
__Smoking
__Drinking alcohol?
__Diet:
__Exercise:
__Allergies?
__Urine: Medication:
__Stool:
__Ambulated?
__ B __F __ V __BM (post op) Vaccines:

Pain:
Pain scale:
 C
 O
 D
 L
 S
 P
 A

8 AM 12 PM 2 PM
Temperature
Pulse rate
Respiration
BP
PHYSICAL ASSESSMENT
Skin, Hair, Skin problem: (lesions, rashes, dryness, oiliness, drainage, bruising, swelling, pigmentation)
and Nails Felling changes: (pain, pressure, itch, tingling)
Hair loss:
Nail changes (Clubbing, pallor):
Nail grooming and cleanliness:
Nail color:
Capillary refill time:
Body odor problem:
Family hx of skin problem/cancer Skin color:
Skin texture:
Skin temperature:
Hair distribution:
Presence of dandruff:

Head and Lumps or lesions:

Neck Inspect size, and shape:
Palpate head consistency:
Inspect face symmetry, movement, and expression:
Palpate temporal artery for tenderness and elasticity:
Difficulty in moving the head and neck:
Dizziness, lightheadedness:
Previous neck and head problems/trauma:
Hx of migraine:
Movement of thyroid cartilage:
Eyes Eye pain:
Redness or swelling:
Hx of a problem in vision:
Ears Ear discoloration:
Ear lesion:
Deformities:
Hearing problem:
Mouth Teeth color:
Tongue color:
Tongue texture:
Uvula in midline:
Nose color:
Nose tenderness/swelling:
Palpate sinuses:
Thorax Difficulty of breathing:
Chest pain:
Cough:
Past surgery:
Hx of lung cancer:
Breast Age of menstruation:
Menopausal:
 LMP:
Given birth:
Age is given birth:
Hx of breast cancer:
Heart Chest pain:
Previous heart prob (heart attack)
Previous heart surgery:
Hypertension:
DM:
Apical pulse:
Stent or pacemaker
Peripheral Skin changes (color, temperature)
vascular Leg pain, heaviness, or aching:
Leg veins (bulging)
Leg sore (location)
Capillary refill time:
Edema: Palpate radial, ulnar and brachial pulse:
Abdomen: Movement:
Sound:
Musculo Weight gain:
Difficulty chewing:
Posture:
Neuro Headache:
Past head injury:
Level of consciousness:
Appearance and behavior:
Observe mood, feelings and expression:
Test for ability of sensation (touch)
Lifestyle Activity of Daily Living:
Exercises:
Sleep pattern:
Medication:
Coping strategies:

Action Done: