Complete Health Assessment Checklist PDF

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COMPLETE HEALTH ASSESSMENT PERFORMANCE CHECKLIST Yes Obtain relevant history Gather equipment Provide privacy Obtain proper lighting Wash hands Ensure visualization of each part as it is examined Observe general appearance of patient Appearance in relation to stated age Obvious physical deformities Mobility Gait Assistive devices ROM Involuntary movements Personal hygiene Clothing Appropriate for season Clean and neat or disheveled Skin color—note throughout exam Examine both hands Inspect nails Posture and position Facial expression and symmetry (CN VII) Affect Mood Speech Articulation Pattern Content appropriate Native language Hearing Vital signs Radial pulse Respirations Blood pressure Temperature Nutritional status Measurement Weight

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Height Skinfold thickness Head and face Observe for Eye contact Level of consciousness Orientation Inspect and palpate Scalp Hair Cranium Face: symmetry Temporal artery, temporomandibular joint Maxillary and frontal sinuses Eyes Test Visual fields by confrontation (CN II) Extraocular muscles Corneal light reflexes Six cardinal positions of gaze (CN III, IV, VI) Vision with Snellen eye chart Pupil Size Response to Light Accommodation Inspect External structures Conjunctiva Sclerae Corneas Irides With ophthalmoscope inspect Ocular fundus Red reflex Disc Vessels Retinal background Ears Inspect external ear With otoscope inspect Canal

Tympanic membrane Test hearing Voice Rinne test Weber test Nose Inspect for Symmetry Lesions Test patency of each nostril With speculum inspect Nasal mucosa Septum Turbinates Mouth and throat Inspect Mouth Buccal mucosa Teeth Gums Tongue Floor of mouth Palate Uvula—condition and mobility Grade tonsils Test Gag reflex (CN IX, X) Stick out tongue (CN XII) Palpate mouth, if indicated Neck Inspect for Symmetry Masses Pulsations Palpate Cervical lymph nodes Carotid pulse Trachea Test ROM Muscle strength Palpate thyroid gland

Chest Inspect Configuration of thoracic cage Skin characteristics Symmetry of shoulders and muscles Palpate for Symmetric expansion Tactile fremitus Masses Tenderness Spinous processes Percuss Lung fields Diaphragmatic excursion Costovertebral angle Auscultate Breath sounds Heart Inspect precordium Pulsations Heave (lift) Palpate Apical impulse—note location Precordium Auscultate Base for murmurs Heart sounds with bell and diaphragm Apical rate Apical rhythm Apex with bell Upper extremities Test ROM Muscle strength of Hands Arms Shoulders Palpate epitrochlear nodes Female breasts Inspect For symmetry For mobility

For dimpling Supraclavicular area Infraclavicular area Palpate Each breast Tail of Spence Axilla Areola Lymph nodes Instruct in breast self-examination Male breasts Inspect Palpate Neck vessels Inspect for jugular venous pulse Estimate jugular venous pressure Abdomen Inspect Contour Symmetry Skin characteristics Umbilicus Pulsation Auscultate for Bowel sounds Vascular sounds Percuss Liver span Location of spleen Palpate all four quadrants, light and deep for Liver Spleen Kidneys Aorta Test abdominal reflexes Inguinal area Palpate each groin for Femoral pulse Inguinal nodes Lower extremities Inspect for Symmetry

Skin characteristics Hair distribution Varicose veins Palpate pulses Popliteal Posterior tibial Dorsalis pedis Temperature Pretibial edema Inspect spaces between toes Test ROM and muscle strength of Hips Knees Ankles Feet Musculoskeletal Note strength during movement Observe Joints Deep knee bends Spine as person touches toes ROM of spine Gait Normal On toes On heels Perform Romberg test Neurologic Test Babinski reflex Position sense of finger One hand Stereognosis Cerebellar function Finger-to-nose Rapid-alternating movements Heel down opposite shin Sensation in selected area on Face Hands Legs Feet

Superficial pain Light touch Vibration Elicit deep tendon reflexes in Biceps Triceps Brachioradialis Patellar Achilles Male genitalia Inspect Penis Scrotum—transilluminate if indicated Palpate Scrotal contents For inguinal hernia Teach testicular self-examination Male rectum Inspect perianal area Palpate Rectal walls Prostate gland Perform occult blood test on stool Female genitalia Inspect Perineal area Perianal area With a speculum Cervix Uterus Perform bimanual examination of Cervix Uterus Adnexa Rectum Rectovaginal walls Perform occult blood test on stool Make age-appropriate modifications when indicated Inform patient that examination is finished Answer questions; discuss further plans after patient is dressed

Document findings Develop a problem list Return equipment...