PHYSICAL ASSESSMENT EVALUATION TOOL (HEAD TO TOE ASSESSMENT) 17. Skin temperature 18. Skin NAILS 19.

Fingernail plate shape 20. Fingernail and toenail bed color 21. Fingernail and toenail texture 22. Tissue surrounding nail 23. Presence of capillaries

NAME OF THE CLIENT: ________________________________________

BODY PART EXAMINED

ACTUAL FINDINGS

ANTHROPOMETRIC MEASUREMENT

1. Measurement in height 2. Measurement in weight BMI = W in kg / H in m GENERAL SURVEY

HEAD SKULL 24. Size, shape, symmetry 25. Presence of nodules, masses, and depressions

3. Body built, height and weight in relation to the clients age, lifestyle, and health 4. Posture, gait, standing, sitting, and walking 5. Overall hygiene and grooming 6. Body and breath odor 7. Signs of distress 8. Signs of health and distress 9. Attitude 10. Mood and affect 11. Quantity and quality of speech SKIN 13. Uniformity of color 14. Presence of edema 15. Lesions according to location distribution, color, configuration, size, shape, type of structure 16. Skin moisture

SCALP 26. Color and appearance 27. Areas of tenderness

HAIR 28. Evenness of growth, thickness or thinness 29. Texture, and oiliness over the scalp FACE 30. Facial features, symmetry of facial movements EYES EYEBROWS 31. Hair

distribution, alignment, skin, quality, and movemen

VISUAL FIELDS 45. Peripheral field EARS AURICLES 46. Color, symmetry, and position 47. Texture, elasticity, and areas of tenderness EXTERNAL EAR CANAL 48. Cerumen, skin lesions, pus, blood

EYELASHES 32. Hair distribution and direction of cur EYELIDS 33. Surface characteristics, position in relation to the cornea, ability to blink, frequency of blinking CONJUCTIVA 34. Bulbar conjunctiva for color, texture, and presence of lesions 35. Palpebral conjunctiva for color, texture, and presence of lesions SCLERA 36. Color and clarity CORNEA 37. Clarity and texture IRIS 38. Shape and colo PUPILS 42. Light reaction and accommodation

HEARING ACUITY 49. Response to normal voice tones 50. Watch tick test 51. Webers test 52. Rinnes test

NOSE 53. Deviations in shape, size, color, and flaring or discharge from nares 54. Nasal cavities for presence of redness, swelling, growths and discharge 55. Nasal septum between nasal chambers 56. Patency of both nasal cavities 57. Tenderness, masses, and displacements of bone and cartilage

EXTRAOCULAR MUSCLE 44. Alignment and coordination SINUSES

58. Tenderness MOUTH LIPS 59. Symmetry of contour, color, and texture

69. Size of the tonsils, color, and discharge NECK AND LYMPH NODES LYMPH NODES 70. Tenderness TRACHEA

BUCCAL MUCOSA 60. Color, moisture, texture, presence of lesion

71. Placement THYROID GLAND 72. Symmetry and visible masses 73. Smoothness and areas of enlargement, masses, or nodules THORAX POSTERIOR THORAX 74. Size, shape, symmetry, compare the diameter of the anteroposterior thorax to the transverse thorax 75. Spinal alignment 76. Temperature, tenderness, masses 77. Respiratory excursion 78. Vocal fremitus 79. Sounds ANTERIOR THORAX 80. Breathing pattern 81. Temperature, tenderness, masses 82. Respiratory excursion 83. Vocal fremitus 84. Sounds 85. Trachea CARDIOVASCULAR PRECORDIUM

TEETH 61. Color, number and condition, and presence of dentures GUMS 62. Color and condition TONGUE/FLOOR OF THE MOUTH 63. Color and texture of the mouth floor and frenulum 64. Texture, movement and base of the tongue 65. Presence of nodules, lumps, or excoriated areas

PALATES AND UVULA 66. Color, shape, texture, presence of bony prominences 67. Position of the uvula and mobility

OROPHARYNX AND TONSILS 68. Color and texture

86. Aortic, pulmonic, tricuspid area 87. Apical area

CAROTID ARTERIES 89. Pulsations and sounds BREAST AND AXILLA BREAST 90. Size, symmetry, contour, shape 91. Skin color, hyperpigmentation, retraction, swelling or edema, lumps AREOLA 92. Size, shape, symmetry, color, surface characteristics, mass or lesions NIPPLES 93. Size, shape, position, color, discharges, lesions, tenderness AXILLARY, SUBCLAVICULAR AND SUPRACVICALAR LYMPH NODES 94. Masses or lumps ABDOMEN 95. Skin integrity, contour, enlargement of liver or spleen, symmetry of contour 96. Visibility of peristalsis movement 97. Visibility of vascular patterns 98. Bowel sounds, vascular and peritoneal friction rubs MUSCULOSKELETAL SYSTEM MUSCLES 99. Size,

contractures, tremors 100. Tonicity, strength (neck, upper, lower extremities) BONES 101. Structure, deformities, tenderness, edema JOINTS 102. Swelling, tenderness, smoothness of movement, crepitation, presence of nodule 103. Range of motion (shoulder and scapula, elbows, hands, acetabulum, popliteal, ankles)