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Diagnose/Impression:
Chief Complaint:
SKIN:
- ( ) Birthmarks , ( ) Lesions, ( ) Thickness, ( ) Turgor, ( ) Edema,
( ) Moister, ( ) Vacularity
- Color –
HEAD:
- ( ) Lesions, ( ) Lice infestation, ( ) Cranial Nerve V, ( ) Cranial Nerve VII,
( ) Head Control
- Shape –
- Hair Color –
EYES:
- ( ) Symmetry, ( ) PERRLA, ( ) Cranial Nerve II, ( ) Cranial Nerve III,
( ) Cranial, Nerve IV, ( ) Cranial Nerve VI
- Conjunctiva –
- Sclera –
EARS:
- ( ) Alignment, ( ) Hearing Acuity, ( ) Cranial Nerve VIII, ( ) Presence of
Foreign Body, ( ) Odor or Discharge
- Position –
NOSE:
- ( ) Alignment, ( ) Symmetry, ( ) Patency, ( ) Presency of Odor, ( ) Discharge,
( ) Lesions, ( ) Flaring of Alae Nasi, ( ) Cranial Nerve I
ABDOMEN:
- ( ) Contour, ( ) Palpable Organs, ( ) Tenderness,
EXTREMITIES:
- ( ) Range of Motion, ( ) Symmetry of Length and Size, ( ) Muscle Tone,
( ) Edema, ( ) Strength
- Number of Fingers –
- Number of Toes –
- Color –
SPINE:
- ( ) Curvature, ( ) Mobility, ( ) Presence of Defects
A Sleep
Hours:
Bedtime Rituals:
C. Nutrition
Food Preferences:
Amount:
Dietary Restrictions:
D. Elimination
- Bowel Pattern:
Color:
Frequency:
Consistency:
Odor:
- Urinary Pattern:
Color:
Frequency:
Consistency:
Odor:
E. Work
Type: Hazards:
G. Others:
B. Laboratory Examinations:
C. Others