SAN PEDRO COLLEGE

NURSING HEALTH ASSESSMENT GUIDE

Part I – HEALTH HISTORY

I.BIOGRAPHICAL DATA
Name of Client: ___________________________________________________________Age:___________Gender:__________
Ward,Unit:___________________________________Bed No.:____________Examiner:_________________________________
Home Address:____________________________________________________________________________________________
Birth Date:_____________________Place of Birth:____________________Nationality:____________Marital Status:_________
Educational Level:_______________Occupation:_________________No. of Dependents:______Religion:__________________

II.CURRENT HEALTH STATUS

Chief Complaint:____________________________________________Impression:_____________________________________
Attending Physician:___________________________Date of Admission:__________Manner of Admisssion:________________
ASK ABOUT: Symptoms experienced__________________________________________________________________________
Onset:________________Duration:________________Frequency:___________________Severity:________________________
Region/Radiation/Related Symptoms:________________________________Precipitating/Palliative Factors:________________
Remedies Given?Initial Treatment ( Before Consultation):_________________________________________________________
Consultation made When:__________________________Where:_______________________Whom:______________________

Notes:

III.PAST HEALTH HISTORY

Personal/Medical History
Arthritis Cancer Depression Diabetes Asthma/ Lung Problem
Heart Disease High Blood Pressure Psychiatric Disease Stroke Thyroid Problem
Epilepsy/Seizure Serious Injuries: (fractures, head injuries,motor accidents, burns, or lacerations)
Other/remarks:___________________________________________________________________________________________
Past Surgical Procedures: Please list previous surgeries with appropriate dates
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Previous Hospitalization/Visits
Reasons of Seeking Care: ___________________________________________Appropriate Date:________________________
Hospital/Health Institution: __________________________________________Physician:_______________________________
Treatment:_______________________________________________________________________________________________
Childhood Illnesses
Mumps Chicken pox Measles Poliomyelitis Ear Infections
Tonsillitis Asthma Diphtheria Others:_________________________________________
Medications: Prescription and non prescription medicines, vitamins, home remedies, birth control pills, herbs,etc.
Name of Drug Medication Dose (e.g mg/pill) How many times a day
_________________________ ______________________________________ _____________________________________
_________________________ ______________________________________ _____________________________________
_________________________ ______________________________________ _____________________________________
Allergies or Drug Reactions: ________________________________________________________________________________
Immunizations: (Childhood)
BCG Hepatitis B DPT OPV Measles Others:________________________
Date of Recent Immunizations
Hepatitis A__________Hepatitis B__________Influenza(flu)__________Varicella__________HPV__________HTIG___________
Tetanus Toxioid__________Pneumonia__________others:________________________________________________________
Allergies: Please list any known allergies:_______________________________________________________________________
Other Concerns
Tobacco Use Cigarettes Never Quit Date:_____________________________________
Current Smoker: Packs/day:_______________No. of Years:________________________________
Alcohol Use Do you drink alcohol? No Yes, No. of drinks per week:__________________________
Drug Use Do you use recreational drugs? No Yes
Have you ever used needles to inject drugs? No Yes
 Sexual activity: Sexually active? Yes No Not Currently
Current Sex Partner(s) is/are: Male Female
Birth Control Method:______________________________________ None Needed
Have you ever had any sexually transmitted diseases (STDs)? No Yes, specify:_____________

Notes:

IV.FAMILY HISTORY
BROTHERS/SISTERS Gender Birthdate Deceased Cause of Death Genetically linked/ Details
(include half-siblings) (M/F) Common Diseases

MATERNAL SIDE
MOTHER GENDER BDATE Deceased Cause of Death Genetically linked/ Details
Common Diseases

GRANDMOTHER

GRANDFATHER

AUNT & UNCLES

FIRST COUSINS

PATERNAL SIDE
FATHER Gender BDATE Deceased Cause of Death Genetically Linked/ Details
Common Diseases

GRANDMOTHER

GRANDFATHER

AUNT & UNCLES

FIRST COUSINS
 V.GORDON’S FUNCTIONAL HEALTH PATTERNS  please follow provided for
A. Health Perception Pattern
B. Nutritional/ Metabolic Pattern
C. Elimination Pattern
D. Sleep/ Rest Pattern
E. Activity/Exercise Pattern
F. Cognitive/Perceptual Pattern
G. Values/Belief Pattern
H. Self-Perception/ Self-Concept Pattern
I. Roles/Relationship Pattern
J. Sexuality/Reproductive Pattern
K. Coping / Stress Tolerance Pattern

Note: Genetically-linked Diseases; Common Diseases- birth defects, specify—premature births –mental retardation, specify—diabetes—hearing loss—heart disease—seizures—
allergies—arthritis—obesity—cancer, specify
I.GENERAL SURVEY NOTES
Body Built Endomorph
Mesomorph
Ectomorph
Height ___cm Weight ___(kg)
Posture / Gait Lordosis
Kyphosis
Scoliosis
Shuffling
Physical Defects, specify
LOC Alert Drowsy Obtunded Stuporous Comatose
Verbal Response Oriented Confused Inappropriate
Incomprehensible None
Grooming well – groomed
disheveled
Orientation oriented
disoriented
Mood appropriate
inappropriate
Vital Signs:
Temperature:________________
Heart Rate:__________________
Pulse Rate:__________________
Respiratory Rate:_____________
Blood Pressure:______________
Pain (PQRST)

II.SKIN NOTES
General Color Uniform Pallor Jaundice
Flushed Cyanotic Bronzing/Tanning
Texture Smooth Rough
Turgor Good Fair Poor
Temperature Warm Cool
Moisture Dry Clammy oily
Lesions: Primary Secondary Vascular
Edema: Pitting Non- pitting
Ulceration:
Exudate Type None Serous Serosanguinous
Purulent Foul purulent
Surrounding Skin: Pink/skin tone reddish/blanchable
white/pallor purple black
Nails well-trimmed jagged edges paronychia koilonychia

III.HEAD NOTES
Configuration Normocephalic Masses
Fontanelles Closed Open
Sunken Bulging
Skull Symmetrical Deformities Depression
Lumps Tenderness
Scalp Clean Dandruff Lice Lesions
Hair Normal Distribution Alopecia
Fine Coarse
Dry Oily
Infestation Hirsutism
Face Symmetrical Movements
Asymmetrical Movements
Involuntary Movements
Paralysis Edema Masses
Muscle Strength of Jaw Normal
Decreased Absent
#rfbg
IV.EYES NOTES
Structure
Eyebrows Aligned Scaly
Symmetrical movements Asymmetrical Movements
Lids Symmetrical Edema Ptosis
Lashes Curled Inward Curled Outward
Lacrimal Duct Normal Swelling
Excessive Tearing Dry
Cornea and Lens Smooth Clear
Lesions Opacity Arcus Senilis
Conjunctiva Pinkish Pale Lesion
Periorbital Region Edema Sunken Discoloration
Sclera Anicteric Icteric Bloodshot
Pupil Isocoric Anisocoric
Reaction to Light
OD Brisk Sluggish Fixed
OS Brisk Sluggish Fixed
Reaction to Accommodation Uniform Unequal
EOMs Normal Nystagmus
Convergence Uniform Unequal
Visual Acuity Grossly Normal with Corrective Lenses
Functional Vision Counting Fingers Hand Movement
Light Perception
Visual Fields Homonymous Hemianopsia
Bitemporal Hemianopsia
Quadrantic Effects

V. EARS NOTES
Pinna Normoset Symmetrical Tenderness
External Canal Impacted Cerumen Discharges
Foul Smelling Serous Purulent Mucoid
Tympanic Membrane (optional) Pearly- Gray Pinkish
Hearing Acuity Normal Deaf

VI.NOSE NOTES
Nasolabial Fold Symmetrical Asymmetrical
Septum Midline Deviated Perforated
Mucosa Pinkish Pale Reddish
Blood Crusts Ulceration
Discharge Serous Purulent
Mucoid Bloody
Patency Both Patent Obstructed
Lesions
Sinuses Non Tender Tender

VII. MOUTH NOTES

Lips Symmetrical Asymmetrical
Color Pinkish Pale Cyanotic
Moisture Moist Dry/Crack
Lesions
Tongue Midline Deviation
Atrophy Fasciculation Lesions
Teeth Complete Missing
Dentures Braces Caries
Discoloration
Gums Pinkish Pale
Bleeding Tender
Mucosa Pinkish Pale
Cyanotic Lesion
Palate Pinkish Pale
Reddish Swelling
#rfbg
VIII.PHARYNX NOTES
Uvula Midline Deviated
Mucosa Pinkish Pale Reddish
Swelling Ulceration
Tonsils Not Inflamed Inflamed
Gag Reflex Positive Negative

IX. NECK NOTES

Trachea Midline Deviated
Lymph Nodes Nonpalpable Palpable/enlarged Tender
Thyroid Nonpalpable Enlarged
Tender Bruit
ROM Normal Rigid
Jugular Vein Distention Present Absent
Muscle Strength Normal Decreased

X.THORAX NOTES
Shape Symmetrical Asymmetrical
Barrel Chest Pigeon Chest Funnel Chest
Spinal Alignment Normal Deformed
Others Bulges Tenderness Lesion
Breathing Pattern Effortless Bradypnea
Tachypnea Dyspnea
Hyperventilation Hypoventilation
Use of accessory muscles
Chest skin Turgor Good Poor
Respiratory Excursion Symmetrical Asymmetrical
Tactile Fremitus Symmetrical Increased Decreased
Percussion Resonant Dull Hyperresonant
Diaphragmatic Excursion ________________R/L (cm)
Breath Sounds Bronchial Vesicular Bronchovesicular
Adventitious Breath Sounds Wheezes Rales/Crackles
Ronchi Friction Rub

XI. HEART NOTES

Precordium Normodynamic Tenderness
Heave Thrill
Heart Sound Distinct Faint
Aortic
Pulmonic
Tricuspid
Apical
Extra Sounds S3 S4 Murmur
Pulse
Temporal Thready Weak Strong Absent
Carotid Thready Weak Strong Absent
Apical Thready Weak Strong Absent
Brachial Thready Weak Strong Absent
Radial Thready Weak Strong Absent
Popliteal Thready Weak Strong Absent
Dorsalis Pedis Thready Weak Strong Absent
Posterior Tibia Thready Weak Strong Absent
Calf Tenderness (Homan’s Sign) Right Positive Negative
Left Positive Negative

XII. BREAST NOTES

Size and Symmetry Equal Unequal
Contour Masses Dimpling
Skin Redness Edema
Tenderness Non-tender Tender
Nipple and Areola Inversion Retraction Edema
Color: _____________________
Discharge: Serous Purulent Mucoid Bloody
XIII. ABDOMEN NOTES
Skin Intact Striae Scars Lesions
Contour Flat Globular Distended
Abnormalities:
Masses Visible Peristaltic wave
Visible Pulsations Bladder Distention
Bowel Sounds
Normoactive Hyperactive
Hypoactive Absent
Vascular Sound Bruit
Friction Rub Absent Present
Percussion Tympanic Hypertympanic
Liver Size: _____________cm (MCL & MSL)
Bladder Palpable Nonpalpable
Ascites Positive Negative
Palpation Muscle Guarding

XIV. GENITO-URINARY SYSTEM NOTES

Female
Pubic Hair Normal Scanty
Labia Symmetrical Assymetrical
Lesions Pinkish
Discoloration Edema
Vagina Discharge
Purulent
Bloody
Foul smelling
Others: swelling Lumps/Nodules
Male
Penis Well - developed
Lesions
Tenderness
Discharge
Purulent
Bloody
Foul Smelling
Meatus Midline Epispadia Hypospadia
Scrotum Symmetrical Asymmetrical
Lesions Tenderness
Enlargement Cryptorchidism
Others Hernia Hydrocele

#rfbg
 SAN PEDRO COLLEGE

PHYSICAL ASSESSMENT GUIDE

Part III – MUSCULOSKELETAL & NEUROLOGICAL ASSESSMENT

MUSCLES: Assess muscles supporting interphalangeal, NOTES

metacarpophalageal, wrist, elbow, shoulder, metatarsophalangeal,
ankles, knees, and hip joints. Specify which muscles correspond to
findings,
Size equal disproportionate atrophy
hypertrophy contractures tremors
flaccidity spasticity
Specify:________________________________________________
______
Test for MUSCLE STRENGTH (Compare L/R)
___sternocleidomastoid ___trapezius
___biceps
___triceps _____finger/wrist ____hip muscles
(raising)
___hip muscles (abduction/adduction) ___hamstring
____quadriceps ___ankles/feet
Weakness
at_________________________________________________
Numbness/Tingling
at__________________________________________

Grade Description
0 No muscular contraction detected
1 A barely detectable trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against some resistance
5 Active movement against full resistance

BONES: Inspect and palpate SKELETAL structure and tenderness. NOTES

Specify which bone corresponds to findings.
Symmetrical strength gross asymmetry
deformity tenderness

Specify:________________________________________________
____

JOINTS. Assess interphalangeal, metacarpophalangeal, wrist, elbow, NOTES

shoulder, metatarsophalangeal, ankles, knees, and hip joints. Specify
which joint corresponds to findings.
symmetrical Bony abnormalities
redness crepitation warmth
swelling tenderness
Specify: ___________________________________________________
Assess Range of Motion of joints (Head to Toe). Specify which joint and
what movement.
Full range of Motion
Specify (joint/movement): ---------------
____________________________________________________________
____________________________________________________________
____________________________________________________________
decreased range of motion
Specify (joint/movement):______________________________________
____________________________________________________________
____________________________________________________________
Others: _____________________________________________________

NEUROLOGICAL ASSESSMENT. Mental status NOTES

Assess speech and language. Briefly describe findings.
Spontaneity____________________________________________
______
Ease and
enunciation__________________________________________
Sophistication___________________________________________
_____
Check for abnormality.
hesitancy stuttering slurred
aphasia,
type_________________________________________
Others_________________________________________________
______________________________________________________
Determine: ORIENTATION – time, place, and person
oriented disoriented
specify___________________
Check for LAPSES IN MEMORY. Describe.
Immediate/ short term
memory_________________________________
Recent
Memory______________________________________________
Remote
Memory______________________________________________
Attention
Span_______________________________________________
LEVEL OF CONSCIOUSNESS
oriented disoriented
specify___________________