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Assessment Guide

Student Name:________________ Client Initials:_____________ Date:__________


General Appearance/Survey
Age:
Gender:
Height:
Weight:

________
________
________
________

Gait:
Posture:
Speech:
Affect:

_________
_________
_________
_________

Other:________________________________________________________________________
_________________________________________________________________
Vital Signs:
T:
_________
O2 Sat: _________

P:__________

R:_________

B/P:________

Pain: Y or N
Onset-_________________________________
Location-_______________________________
Duration-_______________________________
Quality-________________________________
Intensity-_______________________________
Past Medial History:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________
Past Surgical History:
______________________________________________________________________________
______________________________________________________________________________
Current Medications: (name, dose, route, frequency)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Allergies: (medications, food, others & type of reaction)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Integumentary
I.

Skin: consistency__________ color____________ temperature_________

intact______________ turgor___________
edema(describe):_________________________________________
lesions(describe):_________________________________________
bruises(describe):_________________________________________
II.

Hair: texture____________ amount____________ distribution___________


color ____________ balding____________ infestations___________
scalp ____________

III.

Nails: texture___________ color_____________ condition_____________


evidence of infection (describe):______________________________
capillary refill:____________

The Head
I.

Skull: shape ___________ masses____________ tenderness______________


Describe abnormal findings:
__________________________________________________________
__________________________________________________________

II.

Face: symmetry___________ edema (describe)___________________


eyelids______________ exopthalmus___________

III.

Eyes: Pupil Size ________ Response____________ Color___________


Visual Acuity: L_______ R________ B__________
Glasses _________ Contacts___________
Lesions_________ Pstosis ___________ Redness_________
Drainage_________ Conjunctiva _______ Sclera __________
EOM: _____________________________________________

IV.

Ears / Hearing: Auricle _________Level of Ear_________ Aides __________


External Auditory Meatus:_____________________________
Tympanic Membrane:________________________________
Weber __________ Rhine__________ Whisper __________

V.

Nose/Sinuses: Mucosa___________ Color_________ Edema_____________


Discharge _________ Smell _________ Patency____________
Septum ___________ Sinuses : Frontal & Maxillary ________

VI.

Mouth & Oropharynx: Lips: Color __________ Condition_______________


Oral mucosa ________________ Buccal Mucosa___________________
Tongue_____________ Gum____________
Uvula __________ Hard Palate __________ Soft Palate____________
Teeth_______ Dentures________ Gag Reflex ________

Neck

I.
II.
III.
IV.
V.

Muscles: ROM __________ (flexion, extension, hyperextension)


Trachea: midline or deviated
Lymph Nodes: ____________________________________________________
Carotids:______________________ Jugulars:___________________________
Thyroid Gland:____________________________________________________

Thorax & Lungs


I.
II.
III.

Chest: Shape__________ AP to Transverse ___________________


Chest Excursion________________ Tactile Fremitus_______________
Respirations: Rate_______ Depth________ Rhythm________ Symmetry________
Lung Sounds: Anterior _______________ Posterior ________________

Heart- Vascular- Breast-Lymphatics


I.
II.

Heart: PMI_______ AP Rate__________ Sounds___________ Heaves__________


Thrills ______________
Central Vessels: Carotids _______________ Jugulars_______________ CVP______

III.

Peripheral Vascular: B/P: R_______ L________ Standing___________


Edema ____________ (1+ 2+ 3+ 4+) Location_____________
Carotid _____Brachial _____Radial _____ Femoral_______
Popliteal_____Dorsalis Pedis_______ Posterior Tibal _____
Amplitude: absent 0; thready/weak +1; normal +2; increased +3; bounding +4

IV.

Breast & Axillary Lymphatics:


Inspection: ________________________________ (lumps, lesions, discharge,
discoloration, dimpling, other)
Self Exam:___________________ Mammogram:___________________
Axillary Lymph Nodes:________________________________________

Abdomen
I.

II.
III.
IV.

Inspection: contour ______________ size_____________ symmetry__________


lesions _______________ scars____________ distention__________
abdominal girth_______________
Auscultation: bowel sounds: ____________________________
Percussion: __________________________________________
Palpation: __________________________________ (tender/nontender)

Musculoskeletal
Posture:_______________ Tremors: ______________ (intention/resting)
Strength:______________ Gait:______________ Coordination:________________
Contractures:__________ Symmetry:___________ ROM: ____________________
Joint Tenderness:___________ Nodules:________________ Creptius:___________

Neurological
I.

Mental Status: language__________ orientation____________ STM:___________

II.
III.
IV.
V.
VI.

LTM:_________ Attention:_____________ Calculation:_________


Glasgow Coma Scale: Eye Opening _______ Motor ________ Verbal__________
Cranial Nerves: I_____ II_____ III______ IV______ V_____ VI______ VII_____
VIII _____ IX_____ X_____ XI ______ XII______
Reflexes: Biceps________ Patellar________Achilles________Babinski_________
Motor Function: Proprioception__________________ Romberg________________
Sensory Function: Touch __________ Pain___________ Temperature___________
Tactile Discrimination:
2-Point Discrimination____________
Stereognosis____________________
Extinction Phenomena____________

Genitals
I.
II.
III.
IV.

Female: Inspection____________ Inguinal Pulses:__________ Pap Test:__________


Menarche_________ LMP__________ Menopause ________
Male: Inspection______________ Hernias____________ Rectal Exam___________
Urination: color_________ odor____________ amount_____________
frequency__________ urgency___________ dysuria ____________
Rectum: hemorrhoids __________ pain w/ defecation___________ bleeding_______
Occult Blood _________

Additional Notes: