Upt Assessment

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Submitted By lisavelasquez
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Health Assessment
Physical Assessment Documentation Form
Date:__________

Patient Information Patient Initials | | Age | | Sex | |

General Survey

General Observations Does patient appear to be their stated age? | | Level of consciousness | | Skin color | | Nutritional status | | Posture and position | | Obvious physical deformities | | Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement | | Facial expression | | Mood and affect | | Speech: articulation, pattern, content and appropriate, native language | | Hearing | | Personal hygiene | |

Measurements and Vital Signs Weight | | Height | | BMI | | Radial pulse: * rate * rhythm | | Respirations: * rate * depth | | Blood pressure (indicate if sitting or lying) | | Temperature (if indicated) | | Pain assessment | |

Physical Assessment

Skin Hands and nails | | Color and pigmentation | | Temperature | | Moisture | | Texture | | Turgor | | Presence of lesions? | |

Head and Face ScalpHairCranium | | Face (cranial nerve VII) | | Temporal artery and temporomandibular joint | | Maxillary sinuses and frontal sinuses | |

Eyes Visual fields (cranial nerve II) | | Extraocular muscles, corneal light reflex, and cardinal positions of gaze (cranial nerves III, IV, VI) | | External structures | | Conjunctivae, sclerae, and corneas | | Pupils | | Describe the purpose of an Opthalmascope for assessing the eyes | |
Ears
External ear | | Any tenderness? | | Purpose of the otoscope | | Test hearing and conduct the voice test | | Explain the Weber and Rinne tests | |

Nose External nose | | Patency of nostrils | | Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinates | |

Mouth and Throat Lips and…...

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