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Physical Assessment Format
Physical Assessment Format
PHYSICAL ASSESSMENT
Patient’s Name: Age/Sex: Room No.:
AP:
Diagnosis:
Date of Assessment:
Student Nurse/Group:
HEALTH HISTORY
Chief Complaint
Pain of the abrasion wounds on the shoulder, knee, feet, arms, hands, and back.
Current Lifestyle
The patient mentioned that he began consuming alcohol at the age of 16 but have since quit.
He doesn’t smoke and fond of riding motorcycles or going on rides. His dietary preferences
include meat, vegetables, fruits, and fish.
Psychosocial Status
The patient expressed regret for his actions, attributing him to his passion for riding. Despite
facing the consequences of a vehicular accident, he managed to meet their needs and cover
the hospital bills.
TAGUM DOCTORS COLLEGE, INC.
Mahogany St., Rabe Subdivision, Tagum City
College of Allied Health Sciences | Nursing Program
Family History
No data gathered.
Oxygen >96%
Saturation
Level of Awake, alert, and oriented to
consciousness person, place, and time.
<18.5 – Underweight
Body Mass Index 28.5 – 24.9 – Normal
25 – 29.9 – Overweight
30 or higher - Obese