PHYSICAL ASSESSMENT TOOL
(ADULT)
LEVELS I, II, III & IV
Name of Student: ___________________________ Year/Sec/Grp. No: ___________________________
A. GENERAL APPEARANCE
a. body built small frame [ ]
medium frame [ ]
large frame [ ]
b. posture
upright [ ]
stooped [ ]
others___________
c. gait
smooth rhythmic [ ]
staggering [ ] shuffling [ ]
d. dress, grooming, hygiene
appropriately dressed [ ]
well-groomed [ ]
inappropriately dressed [ ]
unkempt [ ]
others [ ]
e. odor (body/breath)
none [ ]
alcohol [ ]
acetone [ ]
cigarette smoke [ ]
others [ ]
f. obvious physical deformity ________________
g. clinical measurements
height: __________ weight: __________
h. vital signs
Temperature: _________ BP: ___________ PR: ___________ RR: ____________
remarks ___________
B. MENTAL STATUS
a. Level of Consciousness
conscious [ ] lethargic [ ]
stuporous [ ] semi-comatose [ ]
deep coma [ ]
b. orientation
time [ ]
place [ ]
person [ ]
remarks ________________
c. emotional status
peasant [ ]
cooperative [ ]
anxious [ ]
angry irritable [ ]
withdrawn [ ]
fearful [ ]
resistive [ ]
euphoric [ ]
others _____________
d. language and communication
use of simple words [ ]
use of technical words [ ]
others ______________ remarks _______________
C. SKIN
a. color
normal skin color [ ]
pallor [ ]
others________________
b. temperature
warm [ ]
cold [ ]
c. moisture
dry [ ]
clammy [ ]
cyanotic [ ]
jaundice [ ]
sweaty [ ]
oily [ ]
erythema [ ]
d. texture
e. turgor
smooth [ ]
rough [ ]
elastic and mobile [ ]
remarks_____________
scaly [ ]
others_____________
wrinkle loss of elasticity [ ]
f. lesions
type________________ location __________________
size_________________ distribution_______________ remarks______________
g. hair distribution __________________________________________
D. NAILS
a. nail plate shape
b. nail condition
c. nail bed color
d. capillary refill
convex 160 [ ]
clubbing [ ]
others ________________
smooth [ ]
rough [ ]
ridged [ ]
brittle [ ]
thick [ ]
thin [ ]
others ______________
pink [ ]
pale [ ]
blue [ ]
others_____________
within 3 seconds [ ]
exceeds 3 seconds [ ]
remarks ________________
E. HEAD AND FACE
a. skull
proportionate to body size [ ]
smooth contour [ ]
disproportionate to body size [ ]
irregular contour [ ]
others______________
b. scalp
tenderness [ ]
lesions [ ]
white [ ]
irregular contour [ ]
others______________
c. hair condition
evenly distribute [ ]
unevenly distributed [ ]
thick [ ]
fine [ ]
brittle [ ]
dull [ ]
shiny [ ]
infestation [ ]
others ______________
d. face
symmetry:
symmetrical [ ]
asymmetrical [ ]
facial movement:
symmetrical [ ]
easy movement [ ]
difficult movement [ ]
asymmetrical [ ]
no movement [ ]
remarks ___________
F. EYES
a. eye condition
straight normal [ ]
strabismus [ ]
b. eyebrows
hair distribution:
thick [ ]
thin [ ]
others_______________
c. eyelid and lashes
palpebral fissure size:
effective closure [ ]
others____________
others______________
none/artificial [ ]
lesions [ ]
fallen eyelashes [ ]
d. blink response
e. eyeballs
bilateral [ ]
frequent [ ]
others_____________
symmetric [ ] form [ ]
sunken [ ]
protruding [ ]
others____________
infrequent [ ]
asymmetric [ ]
unilateral [ ]
hard [ ]
soft [ ]
f. conjunctiva
bulbar:
clear [ ]
palpebral [ ]
pink [ ]
others_______________
g. sclera
white [ ]
leteric [ ]
reddish [ ]
others_____________
h. pupils
size: equal [ ]
unequal [ ]
_____R
_____L
Reaction to light and accommodation:
R brisk [ ]
sluggish [ ]
no reaction [ ]
L brisk [ ]
sluggish [ ]
no reaction [ ]
Visual acuity near vision 12-14 inches away
Able to recognize object [ ]
unable to recognize object [ ] score____________
i. lacrimal apparatus: moist [ ]
excess tearing [ ]
absent tears [ ]
remarks_______________
G. EARS
a. auricle:
1. color:
normal racial tone [ ] cyanosis [ ]
redness [ ]
Others_____________
2. symmetry and size proportion:
symmetric [ ] asymmetric [ ]
Deformity [ ]
3. texture and elasticity:
elastic [ ]
non tender [ ] tender [ ]
firm [ ]
Others______________
b. pinna
recoils when folded [ ]
tenderness [ ]
flaky [ ]
scaly [ ]
lesions [ ]
inflammations [ ]
others____________
c. external canal
some cerumen [ ]
foreign body [ ]
discharges [ ] masses [ ]
impacted serum [ ]
swelling [ ]
redness [ ]
others____________
d. hearing acuity
responds to normal voice [ ] responds to whispered voice (2ft away) [ ]
AD dissiculty [ ]
AS difficulty [ ]
AU difficulty [ ]
remarks______________
H. NOSE
a. external
b. septum
normal racial tone [ ]
flaring [ ]
others_____________
midline [ ]
deviated [ ]
remarks______________
discharge [ ]
perforated [ ]
c. mucosa
d. patency
e. nasal cavity
f. sinuses
I. MOUTH
a. lips
b. mucosa
c. tongue
d. teeth
e. gums
J. PHARYNX
a. uvula:
pink [ ]
pale [ ]
discharges [ ]
both patent [ ]
mass lesion [ ]
obstruction [ ]
others____________ remarks______________
moist [ ]
dry [ ]
discharges [ ]
tender [ ]
non-tender [ ]
remarks____________
pink [ ]
pallor [ ]
cyanosis [ ]
symmetrical [ ]
asymmetrical [ ]
remarks______________
pink [ ]
pallor [ ]
lesions [ ]
remarks______________
midline [ ]
deviation [ ]
R[]
L[]
texture [ ]
rough [ ]
smooth [ ]
color [ ]
pink [ ]
red [ ]
others________________
complete [ ]
incomplete [ ] carries [ ]
remarks ____________
pink [ ]
pallor [ ]
reddish [ ]
remarks ____________
midline [ ]
deviation [ ]
remarks________________
R[]
K. NECK
a. neck muscles
dryness [ ]
moist [ ]
cyanosis [ ]
movable [ ]
atrophy [ ]
dentures [ ]
tender [ ]
mouth sores [ ]
L[]
b. mucosa:
pink [ ]
pallor [ ]
reddish [ ]
c. tonsils:
inflamed [ ]
not inflamed [ ]
R[]
d. posterior pharynx: inflamed [ ]
congested [ ]
remarks___________
e. gag reflex:
lesions [ ]
others_________________
L[]
present [ ]
absent [ ]
remarks____________
equal in size [ ]
swelling [ ]
remarks___________
b. muscle strength (refer to neuro assessment)
c. lymph nodes
palpable [ ]
not palpable [ ]
remarks_____________
ROM [ ]
tender [ ]
not tender [ ]
d. trachea
midline [ ]
deviation [ ]
R[]
L[ ]
remarks____________
e. thyroid gland
palpable [ ]
not palpable [ ]
L. BREAST AND AXILLA
a. symmetry
b. contour
c. skin characteristics
d. lymph nodes
remarks___________________
symmetrical p [ ]
asymmetrical [ ]
flat [ ]
round [ ]
sagging [ ]
smooth [ ]
orange peel appearance [ ]
palpable [ ]
not palpable [ ]
remarks_____________
others______________
masses [ ]
M. CHEST AND LUNGS
a. shape
AP to lateral ratio 1:2 [ ]
barrel [ ]
funnel [ ]
pigeon [ ]
remarks_____________
b. lung expansion
anterior:
symmetrical [ ]
asymmetrical [ ]
posterior:
symmetrical [ ] asymmetrical [ ]
chest excursion 3-5 cm
remarks_____________________________________
c. fremitus
symmetrical [ ]
increase [ ]
R[]
L[]
decrease [ ]
R[]
L[]
d. breathing pattern
regular [ ]
irregular [ ]
use of accessory muscle [ ]
dyspnea [ ]
remarks_____________________________________
e. breath sounds
vesicular [ ]
bronchial [ ]
Broncho vesicular [ ]
rales [ ]
wheeze [ ]
bronchi [ ]
others________________
remarks_____________________________________
f. percussion
resonant [ ]
tympany [ ]
dullness [ ]
hyperresonance [ ]
flatness [ ]
others ______________
g. costal angle
45 degrees [ ]
>45 degrees [ ]
remarks: _______________________________________
h. heart sounds rate___________________________ rhythm________________________________
pulmonic [ ]
aortic [ ]
tricuspid [ ]
remarks: ______________________________________
N. ABDOMEN
a skin integrity
normal racial tone [ ] blemished [ ] unblemished [ ]
lesion [ ]
scar [ ]
rashes [ ]
tense and glistening [ ]
purple striae [ ]
others_______________
b. contour and symmetry
flat [ ] rounded [ ]
scaphoid [ ]
obtunded [ ]
c. movement
d. bowel sounds
e. palpation
f. bladder
g. liver
others_____________
symmetrical [ ]
asymmetrical [ ]
visible peristalsis [ ]
limited movement [ ]
others______________
remarks_______________________________________
normal [ ]
hyperactive [ ] hypoactive [ ] bruits [ ] friction rub [ ]
others______________ remarks__________________________________
muscle guarding [ ]
tender [ ]
masses [ ]
mobile [ ]
fixed [ ]
remarks_____________________________
distended [ ] not distended [ ]
remarks_____________
palpable [ ]
not palpable [ ]
others_______________
remarks______________________________________________
O. UPPER EXTREMITIES
a. motor strength _______________________________________________________________
b. muscle tone _________________________________________________________________
c. lesions ______________________________________________________________________
d. deformity ___________________________________________________________________
e. peripheral pulses
normal [ ]
bounding [ ]
weak [ ]
absent [ ]
f. lymph nodes
palpable [ ]
not palpable [ ]
remarks_________________________________________
g. presence of:
Homan's sign [ ]
varicosities [ ]
phlebitis [ ]
others____________ remarks_______________________
Q. GENITALIA
Male
a. pubic hair
normal distribution [ ]
others__________________
b. penis
circumcised [ ]
not circumcised [ ]
retractable foreskin [ ]
not retractable foreskin [ ]
others__________________
c. urinary meatus
lateral opening [ ]
ventral [ ]
dorsal [ ]
swelling [ ]
others_________________
d. scrotum
symmetrical [ ] asymmetrical [ ] swelling [ ] hydocele [ ] spermatocele [ ]
others_________________
e. testes
descended [ ]
undescended [ ]
unilateral [ ]
bilateral [ ]
f. inguinal hernia
presence [ ]
absence [ ]
remarks ____________________________________
Female (refer to OB/GYNE tool)