Head to Toe Assessment Form
Assessment Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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General Status
Height (in)
Weight (kg)
Body Build
Normal
Obese
Thin
Other
Facial Expression
Anxious
Happy
Sad
Angry
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Vital Signs
Temperature (°F)
Pulse Rate
Beats per minute
Respiratory Rate
Breaths per minute
Blood Pressure (Systolic) mmHg
Blood Pressure (Diastolic) mmHg
Vital Sign
Normal Values
Temperature
97.8°F - 99°F
Pulse Rate
60-100 beats per minute
Respiratory Rate
15-20 breaths per minute
Blood Pressure (Systolic)
less than 120 mmHg
Blood Pressure (Diastolic)
less than 80 mmHg
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Head, Ears, Eyes, Nose, Throat
Eyes
Using glasses
Using contact lens
Using implants
Blind
Pupils
Equal
Round
Reactive to light
Nonreactive to light
Sluggish
Ears
Using implant
Using hearing iad
Presence of drainage
Deaf
Hard to hear
Normal
Hair
Dandruff
Lice
Dry
Normal
Alopecia
Throat
Tonsillitis
Blockage
Swelling
Hard to swallow
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Neck
Motion
Able to move left and right
Able to move up and down
Able to move circular
Trachea
Lesions
Lumps (Goiter)
Large Lymph Nodes
Lymph Nodes
Lumps
Hard Nodules
Tenderness
Enlargment
Is the jugular vein distended?
Yes
No
Are you able to palpate the carotid artery?
Yes
No
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Respiratory
Type of respiration
Normal
Labored
Assymetrical
Cough
None
Dry
Productive
Non-productive
Is there a sputum?
Yes
No
What is the color of the sputum?
Breath Sounds
Clear
Wheezing
No sound
Decreased
Crackles
Friction Rub
Rhonci (Snoring)
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Cardiac
Edema
Absent
Present
Pitting
Anasarca
If edema is present, where it is located?
Tenderness of the calf
(+) Homan's sign
None
Enlarge
Is the jugular vein visible?
Yes
No
Check the following pulses if present in the following parts:
Radial pulses
Pedal pulses
Apical Radial pulses
Carotid pulses
Apical pulse rate
Bradycardia
Tachycardia
Normal
Heart sounds
Normal
Valve click
Murmurs
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Abdomen / Gastrointestinal
Does the patient have any abdominal pain?
Yes
No
Abdominal Status
Distended
Ascites
Invision
Taut
Bowel Movements
Constipation
Diarrhea
Normal
Other
Bowel Sounds
Active
Hypoactive
Hyperactive
Absent
Other
When is the last time you have bowel?
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Extremities
Any deformities on hands or arms?
Yes
No
Are there any redness or swelling on the wrist or hands (IV lines)?
Yes
No
Color of fingernails
Normal color is pink
Status of capillary refill
Normal is less than 2 seconds
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Neurological
Level of Consciousness
Alert
Awake
Lethargic
Confused
Normal
Is the patient oriented to the person, place, and time?
Yes
No
How does the patient communicate?
Verbal
Non-verbal
Aphasia
Expressive
Glasgow Coma Scale
Eye opening
Spontaneous (4)
Verbal command (3)
Pain (2)
No response (1)
Verbal response
Oriented to time, place, and person (5)
Disoriented (4)
Inappropriate words (3)
Incomprehensible sounds (2)
No response (1)
Motor response
Obeys commands (6)
Moves to localized pain (5)
Flexes and withdraws (4)
Abnormal Flexion (3)
Abnormal Extension (2)
No response (1)
Total Score
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Acknowledgment
Health Practitioner Name
First Name
Last Name
Position
Health Care Practitioner Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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