Head-to-Toe Assessment Template
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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: _______________________
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