Clinical Physical Examination Assessment
Complete this form to systematically document findings from a physical examination.
Patient Full Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Age
*
Gender
*
Male
Female
Other
Vital Signs
*
Rows
Value
Unit
Temperature
°C
°F
bpm
mmHg
breaths/min
Pulse
°C
°F
bpm
mmHg
breaths/min
Blood Pressure
°C
°F
bpm
mmHg
breaths/min
Respiratory Rate
°C
°F
bpm
mmHg
breaths/min
General Appearance
*
Well
Ill
Distressed
Other
Systematic Examination Findings
*
Rows
Normal
Abnormal
Comments
Cardiovascular
1
2
Respiratory
3
4
Abdominal
5
6
Neurological
7
8
Musculoskeletal
9
10
Pain Assessment
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Mobility Assessment
*
1
2
3
4
5
Additional Notes or Observations
Examiner Name
*
First Name
Last Name
Submit Assessment
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