Head-to-Toe Assessment

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Introduction

This Head-to-Toe Health Assessment form is a comprehensive tool to evaluate an individual’s physical and physiological health. It provides a systematic approach for assessing critical health parameters. Please complete all sections thoroughly to ensure accurate evaluation and effective health monitoring.

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General Appearance

Evaluation Parameters

• Posture and gait

• Hygiene and grooming

• Signs of distress or discomfort

• Visible deformities

Findings	Notes
Posture is upright and alert. No signs of distress or discomfort observed.	Well-groomed, no visible deformities.

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Vital Signs

Evaluation Parameters

• Temperature: 98.6 °F

• Pulse: 72 bpm

• Respiratory Rate: 16 breaths/min

• Blood Pressure: 120/80 mmHg

• Oxygen Saturation: 98%

Findings	Notes
Vital signs are within normal limits.	Patient is stable and well-hydrated.

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Head and Neck

Evaluation Parameters

• Scalp condition and hair texture

• Facial symmetry and expressions

• Lymph node enlargement

• Thyroid gland size and condition

Findings	Notes
Scalp is healthy, hair is thick and well-kept.	Facial symmetry is normal; no abnormalities.
No enlargement of lymph nodes. Thyroid is not palpable.	No signs of swelling or tenderness.

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Chest and Respiratory System

Evaluation Parameters

• Breath sounds and respiratory rate

• Chest symmetry and expansion

• Presence of wheezing, crackles, or stridor

Findings	Notes
Clear breath sounds bilaterally. Respiratory rate is 16 breaths/min.	Chest expands symmetrically without any signs of distress.
No wheezing, crackles, or stridor noted.	Normal lung function observed.

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Cardiovascular System

Evaluation Parameters

• Heart rate and rhythm

• Peripheral pulses and capillary refill

• Blood pressure and jugular venous pressure

Findings	Notes
Regular heart rate at 72 bpm. No arrhythmias detected.	Peripheral pulses are strong and equal bilaterally. Capillary refill time is 2 seconds.
Blood pressure is 120/80 mmHg, normal range. Jugular venous pressure is within normal limits.	Cardiovascular health appears stable.

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Abdomen

Evaluation Parameters

• Bowel sounds and abdominal tenderness

• Palpation for masses or distension

• Percussion for organ size

Findings	Notes
Bowel sounds are normal, no tenderness reported.	Abdomen soft with no palpable masses or distension.
Percussion of abdomen reveals no abnormalities.	No signs of organ enlargement.

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Musculoskeletal System

Evaluation Parameters

• Joint range of motion

• Muscle strength and tone

• Presence of swelling, deformities, or pain

Findings	Notes
Full range of motion in all joints.	Muscle strength is 5/5 bilaterally in upper and lower extremities.
No swelling, deformities, or pain noted.	Musculoskeletal system appears normal.

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Neurological System

Evaluation Parameters

• Level of consciousness and orientation

• Reflexes and sensory response

• Coordination and motor strength

Findings	Notes
Patient is alert and oriented to person, place, and time.	Reflexes are normal (2+), sensory responses intact.
Motor strength is 5/5 in all extremities. Coordination is intact.	Neurological function is normal.

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Conclusion

Summary of Findings

Overall, the patient appears in good health. All vital signs are stable and within normal limits. No signs of distress or significant abnormalities were noted during the physical exam. Neurological, cardiovascular, musculoskeletal, and respiratory systems are functioning well.

Recommendations

Routine follow-up in 6 months or sooner if any symptoms develop. Continue regular exercise and maintain a balanced diet for overall health.

Summary of Findings	Recommendations
Vital signs stable, no acute issues.	Follow-up in 6 months for routine check-up.

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Evaluator's Signature: _______________________

[YOUR COMPANY NAME]

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