Head-to-Toe Assessment
Patient's Name | Date | Purpose |
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| | |
I. General Appearance
Evaluation Parameters
II. Vital Signs
Temperature | Pulse | Respiratory Rate | Blood Pressure | Oxygen Saturation |
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| | | | |
III. Head and Neck
Evaluation Parameters
Scalp condition and hair texture
Facial symmetry and expressions
Lymph node enlargement
Thyroid gland size and condition
IV. Chest and Respiratory System
Evaluation Parameters
Breath sounds and respiratory rate
Chest symmetry and expansion
Presence of wheezing, crackles, or stridor
V. Cardiovascular System
Evaluation Parameters
VI. Abdomen
Evaluation Parameters
Bowel sounds and abdominal tenderness
Palpation for masses or distension
Percussion for organ size
VII. Musculoskeletal System
Evaluation Parameters
VIII. Neurological System
Evaluation Parameters
Level of consciousness and orientation
Reflexes and sensory response
Coordination and motor strength
Recommendations
Summary of Findings | Recommendations |
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Physician's Signature: _______________________
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