Free Head-to-Toe Assessment Template
Head-to-Toe Assessment
Patient's Name |
Date |
Purpose |
---|---|---|
I. General Appearance
Evaluation Parameters
-
Posture and gait
-
Hygiene and grooming
-
Signs of distress or discomfort
-
Visible deformities
Findings |
Notes |
---|---|
II. Vital Signs
Temperature |
Pulse |
Respiratory Rate |
Blood Pressure |
Oxygen Saturation |
---|---|---|---|---|
Findings |
Notes |
---|---|
III. Head and Neck
Evaluation Parameters
-
Scalp condition and hair texture
-
Facial symmetry and expressions
-
Lymph node enlargement
-
Thyroid gland size and condition
Findings |
Notes |
---|---|
IV. Chest and Respiratory System
Evaluation Parameters
-
Breath sounds and respiratory rate
-
Chest symmetry and expansion
-
Presence of wheezing, crackles, or stridor
Findings |
Notes |
---|---|
V. Cardiovascular System
Evaluation Parameters
-
Heart rate and rhythm
-
Peripheral pulses and capillary refill
-
Blood pressure and jugular venous pressure
Findings |
Notes |
---|---|
VI. Abdomen
Evaluation Parameters
-
Bowel sounds and abdominal tenderness
-
Palpation for masses or distension
-
Percussion for organ size
Findings |
Notes |
---|---|
VII. Musculoskeletal System
Evaluation Parameters
-
Joint range of motion
-
Muscle strength and tone
-
Presence of swelling, deformities, or pain
Findings |
Notes |
---|---|
VIII. Neurological System
Evaluation Parameters
-
Level of consciousness and orientation
-
Reflexes and sensory response
-
Coordination and motor strength
Findings |
Notes |
---|---|
Recommendations
Summary of Findings |
Recommendations |
---|---|
Physician's Signature: _______________________