A health assessment is a set of questions, answered by patients, that asks about

personal behaviors, risks, life-changing events, health goals and priorities, and
overall health.

Head/Face

Face

1. Inspect for facial color, lesions, etc.

2. Inspect for symmetrical facial movements (ask to move eyebrows and to smile)

Hair

3. Inspect distribution and condition of hair

4. Inspect and palpate scalp for bumps, nits, lesions, etc

Head

5. Palpate skull for tenderness, ears, jaw, chin, maxillary sinus, frontal sinus, nose
(ask if there is pain)
6. Assess trigeminal nerve (Feel temporal and mandibular joint place both hands in
the side of face and ask client to open and close mouth and feel for any clicking
sensation)
7. Assess sharp and dull sensation on face

Eyes

1. Inspect symmetry
2. Inspect Eyebrow and eyelash distribution
3. Assess Corneal reflex (shining light between the eyes/ in nose) does the light
reflected at the same spot of the eye bcs if not that may indicate trebismus
4. Check state of conjunctiva and sclera for color (pull the lower eyelid downward
and ask client to look up)
5. Assess pupil should be round, symmetric
 6. Assess if reactive (ask client to look far objects and then from side turn penlight
in their eyes and look if it is constricted. Check both pupils)
7. Assess accommodation reflex (using a pen, move pen towards and away from
the nose ask client to follow it)
8. Do the six cardinal fields of gaze (ask client without moving head to follow
fingers, move each finger to upper mid lower right & vice versa)

Ears

1. Inspect auricle for lesions, tenderness, color, discharge

2. Look inside ear; assess ear discharge and tympanic membrane (using otoscope
pull ear up and inspect)
3. Palpate ear (slightly pull sides and ask if there is pain)
4. Palpate mastoid process (back of the ear, is there any swelling or redness)
5. Do whisper test (ask client to repeat words that are whispered)
6. Assess patient hearing with whisper test (closing the opposite ear whisper and
ask pt to repeat)

Nose

1. Palpate nose and inspect symmetry

2. Check septum and inside nostrils (look for any redness, drainage, polyps)
3. Verify that patient can breathe through each nostril (demonstrate to close each
nostrils and perform inhale exhale and ask if having difficulty in breathing)
4. Verify patient sense of smell is intact

Mouth and Throat

1. Inspect Moistness and color of lips

2. Inspect teeth and gums (ask client to say e)
3. Assess buccal mucosa, palate, tongue, throat inc uvula and tonsils (ask client to
say ah and use tongue depressor ask pt to bring her tongue up)
4. Palpate jaw joint
Neck and Shoulders

1. Palpate the left and the right neck part (put two fingers in the side of the neck)
2. Palpate the trachea and thyroid gland (check for any enlargement)
3. Check skin turgor (by pinching the skin in the under collarbone should be >2 sec)
4. Check neck range of motion (ask to move head UDRL and ask if there’s pain)
5. Check shoulder shrug with resistance (put hands both in shoulder and ask pt to shrug)
6. Palpate neck and trachea/Check for JVD (bulging veins in the neck)
7. Palpate lymph nodes of the head, face, and neck and under the arms (pre
auricular, post auricular, parotid, jugulodigastric, submandibular, submental,
superficial cervical, deep cervical chain, posterior cervical, supraclavicular,
8. Palpate and auscultate carotid artery (using bell of steth ask client to breath in
and out then hold)

Lungs and Thorax

1. Listen to lung sounds front and back

2. Assess respiratory exclusion level
3. Palpate thorax
4. Assess spinal curvature
5. Ask about coughing, respiratory issues

Circulatory System

1. Palpate carotid and temporal artery bilaterally

2. Listen to heartbeat and heart valves

Gastrointestinal System

1. Inspect abdomen
2. Listen to four quadrants of abdomen for bowel sounds
 3. Palpate four quadrants of abdomen for pain/tenderness
4. Ask about problems with bowel or bladder

Arms and Hands

1. Assess range of motion and strength in arms/hands

2. Check all pulses in arms
3. Cap refill test on fingernails
4. Check skin turgor
5. Assess sharp and dull sensation on arms

Legs and Feet

1. Assess range of motion and strength in legs and ankles

2. Check cap refill on toenails
3. Check pulses of legs and feet
4. Assess sharp and dull sensation on legs
5. Assess gait