PHYSICAL ASSESSMENT

Date Performed:
-
1. General Survey
Height: _____
Weight: _____
Body Make- up: ____
Communication Pattern: ________

SKIN:
Color: ____
Turgor: _____
Bruises: ____
Skin Lesion: ________
State of Hydration: ________

HAIR:
Hair color:____________
Scalp:___________

EYES:
Sclera: _____
Pupils: ____

RESPIRATION: Easy Breathing: _√____ In Distress: __x__ No Distress: __x___

2. Vital Signs:
HR: ___/minute
BP Supine R/L arm: ____ /mmHg
BP Sitting R/L arm: 210/140/mmHg
Standing R/L arm: 210/140/mmHg
Temperature: 37.9°C_____
Capillary Refill: ___x__
RR: __20 bpm___

3. Body Position/Alignment:
Supine: ___x__ Fowler’s: _x____ Semi- Fowler’s: _x____
ALIGNMENT: Appropriate: __x___ Not Appropriate: __x___

4. Mental Acuity:
Oriented: __x___ Coherent: __√___ Appropriately responsive: _x____
Disoriented: __x___ Incoherent: __x___ Inappropriately responsive: ___x__

5. Sensory/Motor Restriction:
Amputation: __x___ Deformity: ___x__ Paresis: __x___ Paralysis: __x___
Gait: __x___ Hearing Disorder: ___x__ Speech: __x___
 6. Emotional Status:
Euphoric: __x___ Depressed: __x___ Apprehensive: _x____
Angry/Hostile: __x___ Other: ____x______

7. Medically Imposed Restriction:

CBR w/out BRP: ______x____ BR w/ BRP: ____x______

8. Other Health Related Patterns:

Fatigue: __√__ Restlessness: __√___ Weakness: __√___
Insomnia: _x____ Coughing: ___x__ Dyspnea: __x___
Dizziness: _√____ Pains: __√___ Others: __x___

9. Safety:
Violations of medial asepsis: ______x____
Violations of safety measures: ____x______

10. Activity of Daily Living:

Can/Cannot perform:
Feeding: __x___ Brushing Teeth: ___x__ Bathing: _x___
Dressing: __x___ Combing: _x____ Transferring: _x____

GERIATRIC ASSESSMENT

GENERAL SURVEY
NAME:
SEX:
AGE:
HEIGHT:
WEIGHT: