Free Head-to-Toe Assessment Template

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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: _______________________

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