MENTAL STATUS:

o Oriented o Person o
Place o Time o Date o
Alert o Dull Affect

o Color o Black o Bloody

o Other________________

SPEECH o Clear o
Other_______________
STIMULUS RESPONSE:
o Verbal o Touch o Pain
BEHAVIOR:
o Cooperative
o Uncooperative o
Combative
o Anxious o Depressed
o Restless o Unresponsive
o
Confused(explain)________
_
o Other
(explain)___________
GENERAL:
o Syncope o Dizziness
o Malaise o Seizures
o Memory loss o Insomnia
o Other__________________
HEAD/NECK:
o Symmetrical
o Range of motion
o Oral mucosa o Pink o
Other_____________ o Moist o Dry
o Teeth condition
o Teeth absent
EYES:
o Drainage o Pupils o Equal o
Unequal
o React to light
o Accommodate
Sclera o White o Jaundice O Red
Conjunctiva o Pink o Pale
EARS:
o Drainage
MUSCULOSKELETAL:
o Symmetrical muscles
o Full ROM
o Absence of joint swelling
o Full muscle strength o Steady
gait
o Other___________________
BOWEL HABITS:
o Diarrhea o Constipation
o Date last BM______
o Aids for elimination__________

RESPIRATORY:
Rate_______
Effort o Normal; o Shallow o Hyperpnea o
Wheezing
o Dyspnea o Apneic periods o Orthopnea o
Labored o Painful
o Other______________
Rhythm o Regular o Irregular
Sounds o Equal o Clear o Other
CARDIOVASCULAR:
o Apical pulse o Regular o Irregular o
Rate________
o Jugular Neck Distention o Pain
PERIPHERAL VASCULAR:
Pulses RT LT
o Carotid_____________
o Radial______________
o Brachial____________
o Femoral____________
o Popliteal____________
o Posterior tibial_______
o Dorsalis pedis________
Rhythm o Regular o Irregular
Homans o Pain
Blood pressure o Right arm o Left arm
RENAL/UROLOGICAL:
Urine flow o No problems o Urgency o
Incontinent o Burning o Hesitancy o Dysuria o
Hematuria o Frequency
o Other___________
o Appearance/color__________
GASTROINTESTINAL:
Abdomen o Soft o Distended o Painful o Rigid o
frim o round
o Other_________________
Bowel sounds o hypo o hyper o normal o
absent
o Dysphagia o Trouble chewing
o Nausea o Vomiting o Weight loss o Weight gain

INTEGUMENTARY:
Coloring o Skin o Pink o Cyanotic o
Jaundice
o Other
Texture/Turgor o Dry o Moist o Inelastic
o Other
Nail beds o Pink o Pale o Cyanotic
Capillary blanching__ sec
Edema o Absent o Pedal o Sacral