NAME: _____________________

AGE: ________

VITAL SIGNS: PR= _____________ TEMPERATURE: _________________

RR= _____________ BLOOD PRESSURE: ______________

PARTS TO BE ASSESSED
TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
GENERAL SURVEY
1. Body built, height &
weight in relation to Proportionate and varies
Inspection
client’s age, lifestyle & with lifestyle.
health
Relax, erect posture,
2. Client’s posture & gait,
Inspection coordinated body
standing, sitting & walking
movements.
3. Client’s overall hygiene
Inspection Clean, neat
& grooming
No body odor or minor
body odor relative to work
4. Body & breath odor Inspection
or exercise, no breath
odor.
5. Signs of distress in
posture or facial Inspection No distress noted.
expression
6. Obvious signs of health
Inspection Healthy appearance.
or illness
7. Client’s attitude Inspection Cooperative
8. Client’s affect/mood;
Appropriate to the
appropriateness of the Inspection
situation.
clients response

9. Quantity of speech,
quality & organization
10. Relevance &
organization of thoughts
SKIN
1. Skin color & uniformity Inspection and Palpation
2. Presence of edema
3. Skin lesions
4. Skin moisture
5. Skin temperature
6. Skin turgor
Understandable, moderate
Inspection pace; exhibits thought
association.
Logical sequence; makes
Inspection sense; has sense of
reality.
Color- varies from light to
deep brown; from ruddy
pink to light pink; from
yellow overtones to olive.
Uniformity- generally
uniform except in areas
exposed to sunlight; areas
of lighter pigmentation
(palms, lips, nail beds) in
dark skinned people.
Inspection No edema.
Freckles, some
birthmarks, some flat and
Inspection
raised nevi; no abrasions
or other lesions.
Moisture in skin folds and
axillae (varies with
environmental
Palpation
temperature and humidity,
body temperature and
activity.)
Uniform; within normal
Palpation
range
Palpation When pinched, skin
 springs back to previous
state.
NAILS
1. Fingernails plate shape Convex curvature, angle
to determine its curvature Inspection of nail plate about 160
& angle degrees.
Highly vascular and pink in
light skinned clients; dark-
2. Fingernail & toenail bed skinned clients may have
Inspection
color brown or black
pigmentation in
longitudinal streaks.
3. Tissues surroundings
Inspection Intact epidermis.
nails
4. Fingernail & toenail
Palpation Smooth texture.
texture
Prompt return of pink or
5. Blanch test of capillary
Palpation usual color (generally less
refill
than 4 seconds.)
HAIR & SCALP
1. Evenness of growth
Inspection Evenly distributed hair.
over the scalp
2. Hair thickness &
Palpation Thick/thin hair.
thinness
3. Presence of infections
Inspection Not present.
or infestations
4. Texture & oiliness over
Palpation Silky, resilient hair.
the scalp
SKULL
1. Size, shape & symmetry Palpation Rounded (normocephalic
and symmetrical, with

2. Nodules or masses &
depressions
FACE
1. Facial features
2. Symmetry of the facial
movements
EYEBROWS &
EYELASHES
1. Evenness of distribution
& direction of curl
EYELIDS
1. Surface characteristics Inspection and Palpation
& ability to blink
frontal, parietal, and
occipital prominences);
smooth skull contour.
Smooth, uniform
Palpation consistency; absence of
nodules or masses.
Symmetric or slightly
asymmetric facial
features; palpebral
Inspection
fissures equal in size;
symmetric nasolabial
folds.
Symmetrical facial
Inspection
movements.
Hair evenly distributed;
skin intact. Eyebrows
asymmetrically aligned
Inspection
equal movement.
Eyelashes curl slightly
outward.
Skin intact, no discharge,
no discoloration. Lids close
symmetrically
approximately 15-20
involuntary blinks per
minute; bilateral blinking.
When lids open, no open,
 no visible sclera above
corneas, and upper and
lower borders of cornea
are slightly covered.
CONJUNCTIVA
1. Bulbar conjunctivas
Transparent; capillaries
color, texture & presence Inspection
sometimes evident.
of lesions
2. Palpebral conjunctivas
Shiny, smooth, pink or red
color, texture & presence Inspection
in color.
of lesions
SCLERA
Sclera appears white
1. Color & clarity Inspection (yellowish in dark- skinned
clients).
CORNEA
Transparent, shiny and
smooth; details of the iris
are visible. In older
1.Clarity & color Inspection people, a thin grayish
white ring around the
margin, called arcus
senilis, may be evident.
IRIS
1. Shape & color Inspection Flat and round
PUPILS
Black in color; equal in
1. Color, shape & size; normally 3-7 mm in
Inspection
symmetry of size diameter; round, smooth
border.
2. Pupil light reaction & Inspection Illuminate pupil constricts
 (direct response)
accommodation
Nonillluminated pupil
constricts (consensual
response)
3. Pupils direct & Pupils constrict when
consensual reaction to Inspection looking at near object;
light pupil dilate when looking
at far object; pupils
converge when object is
moved towards the nose.
VISUAL ACUITY
1. Test near vision Inspection Able to read newsprint
20/20 vision on Snellen
2. Test distance vision Inspection
chart.
LACRIMAL GLAND,
LACRIMAL SAC &
NASOLACRIMAL DUCT
No edema or tenderness
1. Presence of edema Inspection
over lacrimal gland.
EXTRAOCULAR
MUSCLES
Both eyes are
1. Test each eye for coordinated; move in
Inspection
alignment & coordination unison, with parallel
alignment.
VISUAL FIELDS
When looking straight
1. Test for peripheral
Inspection ahead, the client can see
visual fields
objects in the periphery.
EAR’S AURICLE
 Color same as facial skin,
symmetrical, auricle
1. Color & symmetry of
Inspection aligned with outer canthus
size & position
of eye, about 10cm from
vertical.
Mobile, firm and not
2. Texture & elasticity &
Palpation tender, pinna recoils after
areas of tenderness
it is folded.
EXTERNAL EAR CANAL
Distal third contains hair
1. Cerumen, skin lesions, follicles and glands. Dry
Inspection
pus & blood cerumen in various shades
of brown
HEARING AUITY TEST
1. Client’s response to Normal voice tones
Inspection
normal voice tones audible
Able to hear ticking in
2. Perform watch tick test Inspection
both ears
NOSE
1. Shape, size or color & Symmetric and straight
flaring or discharge from Inspection No discharge or flaring
the nares Uniform color
2. Presence of redness,
Mucosa pink
swelling, growths &
Inspection Clear, watery discharge
discharge or nares using
No lesions.
the flashlight
3. Position of nasal Nasal septum intact and in
Inspection
septum midline, intact
Air moves freely as the
4. Test patency of both
Inspection client breathes through
nasal septum
the nares
5. Tenderness, masses &
displacement of bone &
cartilage
SINUSES
1. Presence of tenderness
LIPS
1. Symmetry of contour
Inspection and Palpation
color & texture
BUCCAL MUCOSA
1. Color, moisture, texture
Inspection and Palpation
& presence of lesions
TEETH
1. Inspect for color,
number & condition &
presence of dentures
GUMS
1. Color & condition
Palpation Not tender; no lesions
Palpation Not tender
Uniform pink color
(darker, e.g., bluish hue,
in Mediterranean groups
and dark-skinned clients)
Soft, moist, smooth
texture
Symmetry of contour
Ability to purse lips
Uniform pink color
(freckled brown
pigmentation in dark-
skinned clients)
Moist, smooth, soft,
glistening, and elastic
texture (drier oral mucosa
in elderly due to
decreased salivation)
32 adult teeth
Inspection Smooth, white, shiny
tooth enamel
Inspection Pink gums (bluish or dark
patches in dark-skinned
 clients)
Moist, firm texture to
gums

TONGUE/FLOOR OF THE
MOUTH
1. Color & texture of the Smooth tongue base with
Inspection and Palpation
mouth floor & frenulum prominent veins
Central in position

Pink in color (some brown

pigmentation on tongue
borders in darj-skinned
clients); moist; slightly
2. Position, color &
rough; thin white coating
texture, movement & base Inspection and Palpation
Smooth, lateral margins,
of the tongue
no lesions
Raised papillae (taste
buds)

Moves freely, no
tenderness
PALATES & UVULA
Soft palate- light pink,
1. Color & shape, texture smooth, no lesions, moist.
& presence of bony Inspection and Palpation Hard palate- lighter pink,
prominences more irregular
texture/ridges no lesions
2. Position of the uvula & Positioned in midline of
Inspection
mobility soft palate.
 OROPHARYNX &
TONSILS
1. Color & texture
2. Size of the tonsils, color
& discharge
3. Gag reflex
NECK & LYMPH NODES
1. Symmetry & visible
mass in the thyroid gland
2. Presence of tenderness
or nodules in the lymph
nodes
3. Placement of the
trachea
4. Smoothness & areas of
enlargement, masses or
nodules in the thyroid
gland
POSTERIOR THORAX
1. Shape, symmetry &
compare the diameter of
antero posterior thorax to
transverse diameter
2. Spinal alignment
3. Breathing excursion
Pink and smooth posterior
Inspection and Palpation
wall.
Tonsils are of normal size
Inspection or not visible, pink in color
and smooth. No discharge.
Inspection Present
Inspection Not visible on inspection
Inspection and Palpation Not palpable.
Central placement in
Inspection midline of neck, spaces
are equal on both sides.
Lobes may not be
palpitated. If palpitated,
lobes are small, smooth,
Inspection
centrally located, painless,
and rise freely with
swallowing.
Anteroposterior to
Inspection transverse diameter ratio
of 1:2, chest is symmetric.
Inspection Spine vertically aligned.
No adventitious breath
Inspection
sounds.

4. Respiratory excursion
5. Temperature,
tenderness, masses
6. Vocal fremitus
7. Percuss the posterior
thorax
8. Auscultate the posterior
thorax
ANTERIOR THORAX
1. Breathing pattern
2. Temperature,
Inspection and Palpation
tenderness, masses
3. Respiratory excursion
Full and symmetric
expansion (when client
takes a deep breath, your
thumbs should move apart
Inspection an equal distance and at
the same time; normally
the thumb separates 3 to
5 cm or 1 ½ to 2 in during
deep inhalation.)
Uniform skin temperature,
Palpation
no masses or tenderness.
Bilateral symmetry of
vocal fremitus.
Inspection Fremitus is heard most
clearly at the apex of the
lungs.
Percussion notes resonate,
except over scapula.
Percussion
Lowest point of resonance
is at the diaphragm.
Vesicular and
Auscultation bronchovesicular breathe
sounds.
Quiet, rhythmic, and
Inspection
effortless respirations.
Uniform skin temperature,
no masses or tenderness.
Full symmetric excursion,
Inspection thumbs normally
separates 3 to 5 cm.
 Same as posterior vocal
fremitus; it is normally
4. Vocal fremitus Inspection
decreased over heart and
breast tissue.
Percussion notes resonate
down to the sixth rib at
the level of the diaphragm
but are flat over areas of
5. Percuss the anterior
Percussion heavy muscle and bone,
thorax
dull on areas over the
heart and the liver, and
tympanic over the
underlying stomach.
Bronchial and tubular
6. Auscultate the trachea Auscultation
breath sounds.
7. Auscultate the anterior Bronchovesicular and
Auscultation
thorax vesicular breath sounds.
CAROTID ARTERIES
1. Pulsation of carotid No pulsations, lifts or
Palpation
arteries heaves.
2. Auscultation of the No sound heard on
Auscultation
carotid arteries auscultation.
JUGULAR VEIN
1. Visibility of jugular vein Inspection Veins not visible.
ABDOMEN
Unblemished skin, uniform
in color, silver white striae
1. Skin integrity Inspection
(stretch marks) or surgical
scars.
Flat, rounded (convex) or
2. Abdominal contour Inspection
scaphoid(concave)
 No evidence of
3. Enlarge liver or spleen Palpation enlargement of liver or
spleen.
4. Symmetry of contour Inspection Symmetric contour.
Symmetric movements
caused by respiration.
Visible peristalsis in very
5. Abdominal movements Inspection
lean people. Aortic
pulsations in thin persons
at epigastric area.
No visible vascular
6. Vascular patterns Inspection
pattern.
Audible bowel sounds,
7. Bowel sounds, vascular
Auscultation absence of arterial bruit
sound & peritoneal sounds
and friction rubs.
Tympanic sound over the
stomach and gas-filled
8. Percuss abdominal bowels; dullness,
Percussion
quadrants especially over the liver
and spleen or in full
bladder.
Tenderness may be
9. Light palpation of present near xiphoid
Palpation
abdominal quadrants process, over cecum, and
over sigmoid colon.
MUSCOLOSKELETAL
SYSTEM
1. Muscle size compare Inspection Equal size on both sides of
the muscles on one side of body.
the body (arm, thigh, calf)
to the same muscle on the
 other side
2. Constructures
(shortening) of the Inspection No contractures.
muscles & tendons
3. Muscle fasciculation’s &
tremors. Presence of
tremors of the hands & Inspection No tremors.
arms when stretched in
front of the body
4. Muscle tonicity Inspection Normally firm.
Equal strength on each
5. Muscle strength Inspection
body side.
BONES
1. Normal structure Inspection No deformities.
2. Edema & tenderness Inspection No tenderness or swelling.
JOINTS
1. Swelling Inspection No swelling.
2. Presence of tenderness,
No tenderness, swelling,
smoothness of movement,
Inspection crepitation or nodules.
swelling, crepitation &
Joints move smoothly.
presence of nodules
RANGE OF MOTION
Uniform in color, veins are
visible in face, neck and
dorsum of the hands,
1. Upper extremities Inspection
average muscles size,
fingers are complete
No lesions, no edema.
Uniform in color, no
2. Lower extremities Inspection deformities, complete
fingers in both feet.