Congestive Heart Failure Physical Exam Form
Document key physical findings relevant to congestive heart failure in a focused, minimal format.
Patient Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
General Appearance
*
Comfortable at rest
Dyspnea at rest
Orthopnea
Other
Jugular Venous Pressure (JVP)
*
Not elevated
Elevated
Unable to assess
Lung Auscultation
*
Clear
Crackles (Rales)
Wheezing
Diminished breath sounds
Heart Sounds
*
Normal S1/S2
S3
S4
Murmur
Peripheral Edema
*
Absent
Present - Mild
Present - Moderate
Present - Severe
Hepatojugular Reflux
*
Negative
Positive
Not assessed
Blood Pressure (mmHg)
*
Additional Notes
Submit Exam
Should be Empty: