I.

General Survey NOTES

Body Built: □ Endomorph

□ Mesomorph
□ Ectomorph
Height: __ (cm) Weight: __ (kg)

Posture/Gait: □ Lordosis

□ Kyphosis
□ Scoliosis
□ Shuffling
□ Physical defects
LOC: □alert □drowsy □obtunded

□stuporous □comatose
Verbal Response: □oriented

□confuse □inappropriate
□incomprehensible □none
Grooming: □well-groomed

□disheveled
Orientation: □Oriented

□Disoriented
Mood: □appropriated

□Inappropriate
Vital Signs:
Temp.___________

HR______________

PR______________

RR______________

BP______________

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
IV. Eyes Notes Notes
Structure: EOMs: □normal □nystagmus

Eyebrows: □Aligned □scaly Convergence: □Uniform □Unequal

□symmetrical movements Visual acuity: □Grossly normal

□asymmetrical movements □With corrective lenses

Lids: □Symmetrical □Edema □Ptosis Functional Vision: □counting fingers

Lashes: □curled inward □Hand movement

□curled outward □Light perception
Lacrimal duct: □normal □swelling Visual fields: □homonymous

□excessive tearing □dry hemianopsia

Cornea & Lens: □Smooth □Clear □bitemporal

□Lesions □Opacity □Arcus Senilis hemianopsia

Conjunctiva: □Pinkish □Pale □quadrantic effects

□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
V. Ears Notes

Pinna: □Normoset □Symmetrical

□Tenderness
External canal: □Impacted cerumen

□Discharge: □Foul smelling

□Serous □Purulent □Mucoid
Tympanic membrane: (optional)

□pearl-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

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
IX. Thorax Notes Notes

Shape: □Symmetrical Tactile Fremitus: □Symmetrical

□Asymmetrical □Increased □Decreased

□Barrel chest Percussion: □resonant □dull

□Pigeon chest □Hyperesonant

□Funnel chest Diaphragmatic excursion:
__________ R/L (cm)
Spinal alignment: □Normal
Breath sounds □Bronchial
□Deformed
□Vesicular
Others: □Bulges □Tenderness
□Bronchovesicular
□Lesion
Adventitious breath sounds:
Breathing Pattern:
□Wheezes
□Effortless □Bradypnea
□Rales/crackles
□Tachypnea □Dyspnea
□Ronchi
□Hyperventilation
□Friction rub
□Hypoventilation
□Use of accessory muscles
Chest skin turgor: □poor □good

Respiratory Excursion:

□Symmetrical
□Asymmetrical
X. Heart Notes Notes

Precordium: □Normodynamic Radial: □Thready □Weak

□Tenderness □Strong □Absent
□Heave Popliteal: □Thready □Weak

□Thrill □Strong □Absent

Heart Sound: Distinct Faint Dorsalis Pedis: □Thready □Weak

Aortic □ □ □Strong □Absent

Pulmonic □ □ Posterior Tibia: □Thready □Weak

Tricuspid □ □ □Strong □Absent

Apical □ □
Extra sounds: □S3 □S4 Calf Tenderness: (Homan’s sign):

□Murmur Right □Positive □Negative

Pulses: Left □Positive □Negative

Temporal: □Thready □Weak

□Strong □Absent
Carotid: □Thready □Weak
□Strong □Absent
Apical: □Regular □Irregular
Brachial: □Thready □Weak
□Strong □Absent
XI. Breast Notes

Size and Symmetry: □Equal

□Unequal
Contour: □Masses □Dimpling

Skin: □Redness □Edema

Tenderness: □Tender

□Non-tender
Nipple and Areola □Inversion

□Retraction □Edema
Color: _________

□Discharge:
□Serous □Purulent
□Mucoid □Bloody
XII. 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: □Tympanitic

□Hypertympanitic
Liver size: ___cm (MCL & MSL)

Bladder: □Palpable □Non-palpable

Ascites: □Positive □Negative

Palpation: □Muscle guarding

□Tenderness
XIII. Genito-Urinary System Notes Notes
Female Male

Pubic Hair: □normal Penis: □Well-developed

□Scanty □Lesions
Labia: □Symmetrical □Tenderness
□Asymmetrical □Discharge:
□Lesions □Purulent
□Pinkish □Bloody
□Discoloration □Foul-smelling
□Edema Meatus: □Midline

Vagina: □Epispadia
□Discharge: □Hypospadia
□Purulent
□Bloody Scrotum: □Symmetrical

□Foul-smelling □Asymmetrical
Others: □Swelling □Lesions
□Lumps/nodules □Tenderness
□Enlargement
□Cryptorchidnism
Others: □Hernia
□Hydrocele
 PHYSICAL ASSESSMENT GUIDE
Part III – MUSCULOSKELETAL & NEUROLOGICAL ASSESSMENT

MUSCLES: Assess MUSCLES supporting interphalangeal,

metacarpophalangeal, 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 ___fingers/wrist ___hip muscles (raising)
___hip muscles (abduction/adduction) ___hamstring
___quadriceps ___ankles/feet
Weakness at_____________________________________________
Paralysis 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 Specify
which bone corresponds to the following findings.

□Symmetrical length □gross asymmetry

□Deformity □tenderness
Specify_________________________________________________________

JOINTS: Assess interphalangeal, metacarpophalangeal, wrist, elbow, 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-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
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, & person.

□oriented □disoriented Specify____________________

Check for LAPSES IN MEMORY. Describe.

Immediate/short term memory:__________________________________
Recent memory:______________________________________________
Attention span:_______________________________________________
LEVEL OF CONSCIOUSNESS

□oriented □disoriented Specify____________________

 GORDON’S FUNCTIONAL HEALTH PATTERNS
I.HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN
1. History
a. How has general health been?
b. Any colds in past year? When appropriate absences from work?
c. Most important things you do to keep healthy? Think these things make a difference to health?
(Include family folk remedies when appropriate.) Use of cigarettes, alcohol, drugs? Breast self-
examination?
d. Accidents (home, work, driving)?
e. In past, been easy to find ways to follow suggestions from physicians or nurses?
f. When appropriate: what do you think caused this illness? Actions taken when symptoms
perceived? Results of action?
g. When appropriate: things important to you in your health care? How can we be most helpful?
2. Examination—general health appearance
II.NUTRITIONAL METABOLIC PATTERN
1. History
a. Typical daily food intake? (Describe) Supplements (vitamins, type of snacks)?
b. Typical daily fluid intake? (Describe)
c. Weight loss or gain? (Amount) Height loss or gain? (Amount)
d. Appetite
e. Food or eating: Discomfort? Swallowing? Diet restrictions?
f. Heal well or poorly?
g. Skin problems: Lesions? Dryness?
h. Dental problems?
2. Examination
a. Skin: Bony prominences? Lesions? Color changes? Moistness?
b. Oral mucous membranes: Color? Moistness? Lesions?
c. Teeth: General appearance and alignment? Dentures? Cavities? Missing teeth?
d. Actual weight, height
e. Temperature
f. Intravenous feeding-parenteral feeding (specify)?
III. ELIMINATION PATTERN
1. History
a. Bowel elimination pattern? (Describe.) Frequency? Character? Discomfort? Problem in control?
Laxatives?
b. Urinary elimination pattern? (Describe.) Frequency? Problem in control?
c. Excessive perspiration? Odor problems?
d. Body cavity drainage, suction, and so on? (Specify.)
2. Examination- when indicated: examine excreta or drainage color and consistency
IV. ACTIVITY- EXERCISE PATTERN
1. History
a. Sufficient energy for desired or required activities?
b. Exercise pattern? Type? Regularity?
c. Spare-time (leisure) activities?
Perceived ability (code for level) for: Feeding _______ Dressing ______ Cooking ______
Bathing _____ Grooming _____ Shopping _____ Toileting ______
General Mobility ______ Bed Mobility ______ Home maintenance ________
Functional Level Codes:
Level 0: full self-care
Level I: requires use of equipment or device
Level II: requires assistance or supervision from another person
Level III: requires assistance or supervision from another person and equipment or device
Level IV: is dependent and does not participate
2. Examination
a. Demonstrated ability (code listed above) for:
Feeding_______ Dressing_________ Cooking________
Bathing________ Grooming________ Shopping_______
Toileting_______ General Mobility__________
b. Gait________ Posture_________ Absent body part? (Specify.)________
c. Range of motion (joints)________ Muscle firmness_________
d. Hand grip________ Can pick up a pencil? ________
e. Pulse (rate)_______ (rhythm)_________ Breath sounds_________
f. Respirations (rate)_________ (rhythm)________ Breath sounds_________
g. Blood pressure__________
h. General appearance (grooming, hygiene, and energy level)
V. SLEEP-REST PATTERN
1. History
a. Generally rested and ready for daily activities after sleep?
b. Sleep onset problems? Aids? Dreams (nightmares)? Early awakening?
c. Rest- relaxation periods?
2. Examination
a. When appropriate: Observe sleep pattern
VI. COGNITIVE-PERCEPTUAL PATTERN
1. History
a. Hearing difficulty? Hearing aid?
 b. Vision? Wear glasses? Last checked? When last changed?
c. Any change in memory lately?
d. Important decision easy or difficult to make?
e. Easiest way for you to learn things? Any difficulty?
f. Any discomfort? Pain? When appropriate: How do you manage it?
2. Examination
a. Orientation
b. Hears whisper?
c. Reads newsprint?
d. Grasps ideas and questions (abstract, concrete)?
e. Language spoken
f. Vocabulary level. Attention span.
VII. SELF-PERCEPTION---SELF-CONCEPT PATTERN
1. History
a. How describe self? Most of the time, feel good (not so good) about self?
b. Changes in body or things you can’t do? Problem to you?
c. Changes in way you feel about self or body (since illness started)?
d. Things frequently make you angry? Annoyed? Fearful? Anxious?
e. Ever feel you lose hope?
2. Examination
a. Eye contact. Attention span (distraction).
b. Voice and speech pattern. Body posture
c. Nervous (5) or relaxed (1); rate from 1 to 5.
d. Assertive (5) or passive (1); rate from 1 to 5.
VIII. ROLES-RELATIONSHIPS PATTERN
1. History
a. Live alone? Family? Family structure (diagram)?
b. Any family problems you have difficulty handling (nuclear or extended)?
c. Family or others depend on you for things? How managing?
d. When appropriate: How family or others feel about illness or hospitalization?
e. When appropriate: Problems with children? Difficulty handling?
f. Being to social groups? Close friends? Feel lonely (frequency)?
g. Things generally go well at work? (School?)
h. When appropriate: Income sufficient for needs?
i. Feel part of (or isolated in) neighborhood where living?
2. Examination
a. Interaction with family member(s) or others (if present)
IX. SEXUALITY-REPRODUCTIVE PATTERN
1. History
a. When appropriate to age and situations: Sexual relationship satisfying? Changes? Problems?
b. When appropriate: use of contraceptives? Problems?
c. Female: When menstruation started? Last menstrual period? Menstrual problems? Para?
Gravida?
 2. Examination: None
X. COPING-STRESS TOLERANCE PATTERN
1. History
a. Any big changes in your life in the last year or two? Crisis?
b. Who’s most helpful in talking things over? Available to you now?
c. Tense or relaxed most of the time? When tense, what helps?
d. Use any medicines, drugs, alcohol?
e. When (if) have big problems (any problems) in your life, how do you handle them?
f. Most of the time is this (are these) way(s) successful?
2. Examination: none
XI. VALUES-BELIEFS PATTERN
1. History
a. Generally get things you want from life? Important plans for the future?
b. Religion important in life? When appropriate: Does this help when difficulties arise?
c. When appropriate: will being here interfere with any religious practices?
2. Examination: None
OTHER CONCERNS
1. Any other things we haven’t talked about that you would like to mention?
2. Any questions?
 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 & Time of Admission: ______Manner of Admission: ___________

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 vehicle accidents, burns, or lacerations)
Others/ remarks: ___________________________________________________________________

Past Surgical Procedures. Please list previous surgeries with approximate dates.
_________________________________________________________________________________
_________________________________________________________________________________
Previous Hospitalization/ Visits
Reasons of seeking care: ________________________________ Approximate 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 the Drug Medication Dose (e.g., mg/pill) How many times per day
____________________ __________________________ __________________________
____________________ __________________________ __________________________
____________________ __________________________ __________________________
Allergies or drug reactions: ___________________________________________________________
Immunizations. Childhood Immunizations

□ BCG □ Hepatitis B □ DPT □ OPV □ Measles Others______________

Date of most recent immunizations

Hepatitis A _______ Hepatitis B ______ Influenza (flu) ______ Varicella ______ HPV ____________
HTIG ________ Tetanus Toxoid _______ Pneumonia _______ Others: ________________________
Allergies. Please list any known allergies:________________________________________________
Other Concerns

Tobacco Use □ Cigarettes □ Never □ Quit Date: __________

 □ Current smoker: Packs/day ________ No. of yrs: _________
Alcohol Use Do you drink alcohol? □ No □ Yes No. of drinks/week:_________

Drug Use Do you use any 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 Birth Decease Cause of Genetically linked/ Details

Date d Death Common diseases
(include half-siblings) (M/F)
MATERNAL SIDE

MOTHER Gende Birth Deceased Cause of Genetically linked/ Details

r date Death Common diseases

GRANDMOTHER

GRANDFATHER

AUNTS AND UNCLES

FIRST COUSINS
PATERNAL SIDE

FATHER Gende Birth Deceased Cause of Genetically linked/ Details

r date Death Common diseases

GRANDMOTHER

GRANDFATHER

AUNTS AND UNCLES

FIRST COUSINS
V. GORDON’S FUNCTIONAL PATTERNS  please follow provided for
a. Health Perception- Health Management Pattern f. Cognitive-Perceptual Pattern
b. Nutritional- Metabolic Pattern g. Values- Belief Pattern
c. Elimination Pattern h. Self- Perception- Self- Concept Pattern
d. Sleep- Rest Pattern i. Roles- Relationship Pattern
e. Activity- Exercise Pattern j. Sexuality- Reproductive Pattern
k.Coping- Stress Tolerance Pattern