BROKENSHIRE COLLEGE

MADAPO, DAVAO CITY

NURSING ASSESSMENT TOOL

I. HEALTH HISTORY
A. Biographical Data
Name of Client: ___________________________________________________________________________
Address: ________________________________________________________________________________
Age: _______________ Date of Birth:________________ Tel No. __________________________________
Sex:_______________ Marital Status: ________________Occupation: ______________________________
Source of Information: _____________________________________________________________________
Date and Time History was Taken: ___________________________________________________________

B. Chief Complaint(s) Reason(s) for seeking health care:

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C. History of Present Illness (if any):

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D. Past Medical History:

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E. Present Health:
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F. Past Health History:

Childhood Illness:
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Accidents/Injury:
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Serious or Chronic Disease:

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Hospitalizations:
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Obstetric History:
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Immunization:
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Last exam date (Dental, Vision, Hearing, ECG, Chest X ray):
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Allergies:
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Current Medications:
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Habits:
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Activities of Daily Living (hygiene and grooming practices; Ambulation, self care, etc.):
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Recent Travel:
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Family History of Illness (attach genogram):

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Personal and Social History:

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Family Members at Home:

NAME AGE RELATIONSHIP

Economic History (source of Income, Livelihood, financial assistance, etc.)

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II. REVIEW of Systems
I. Integument (Skin, Hair and Nails)
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II. Head
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III. Eye structures & Visual Acuity

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IV. Ears & Hearing

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V. Nose and Sinuses

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VI. Mouth an Oropharynx

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Neck
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VII. Thorax and Lungs

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VIII. Heart and Central Vessels

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IX. Peripheral Vascular System

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X. Breast and Axillae

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XI. Abdomen
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XII. Musculoskeletal System

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XIII. Neurological System

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XIV. Genitals and Inguinal Area

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XV. Rectum and Anus

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 ____________________________________________________________________________________
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III. Physical Examination

I. General Appearance and Mental Status
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II. Vital Signs/Measurement

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III. Integument
a. Skin
Inspection
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Palpation
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Percussion
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Auscultation
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b. Hair
Inspection
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Palpation
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Percussion
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Auscultation
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c. Nails
Inspection
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Palpation
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Percussion
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Auscultation
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IV. Head
a. Skull
Inspection
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Palpation
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Percussion

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 _________________________________________________________________________________
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Auscultation
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b. Face
Inspection
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Palpation
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Percussion
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Auscultation
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V. Eye Structure & Visual Acuity

a. External Eye Structure
b. Visual Fields
c. Extaocular Muscle
d. Visual Acuity
Inspection
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Palpation
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Percussion
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Auscultation
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VI. Ears and Hearing

Inspection
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Palpation
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Percussion
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Auscultation
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VII. Nose and Sinuses

a. Nose
Inspection
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 Palpation
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Percussion
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Auscultation
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b. Facial Sinuses
Inspection
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Palpation
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Percussion
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Auscultation
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VIII. Mouth and Oropharynx

a. Lips and Buccal mucosa
Inspection
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Palpation
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Percussion
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Auscultation
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b. Teeth and gums

Inspection
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Palpation
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Percussion
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Auscultation
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c. Tongue/Floor of the mouth

Inspection

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 _________________________________________________________________________________
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Palpation
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Percussion
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Auscultation
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d. Salivary Glands
Inspection
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Palpation
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Percussion
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Auscultation
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e. Palates and Uvula

Inspection
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Palpation
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Percussion
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Auscultation
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IX. Neck
a. Neck muscles
Inspection
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Palpation
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Percussion
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Auscultation
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b. Lymph nodes

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 Inspection
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Palpation
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Percussion
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Auscultation
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c. Trachea
Inspection
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Palpation
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Percussion
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Auscultation
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d. Thyroid Gland
Inspection
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Palpation
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Percussion
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Auscultation
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X. Thorax and Lungs

a. Posterior thorax
Inspection
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Palpation
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Percussion
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Auscultation
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 b. Anterior thorax
Inspection
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Palpation
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Percussion
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Auscultation
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XI. Heart and Central Vessels

Inspection
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Palpation
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Percussion
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Auscultation
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XII. Peripheral Vascular System

Inspection
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Palpation
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Percussion
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Auscultation
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XIII. Breast and Axillae

Inspection
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Palpation
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Percussion
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Auscultation
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XIV. Abdomen
Inspection
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Palpation
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Percussion
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Auscultation
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XV. Musculoskeletal System

a. Muscles
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b. Bones
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c. Joints
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XVI. Neurological System

a. Language
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b. Orientation
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c. Memory
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d. Attention Span and Circulation

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e. Level of consciousness
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f. CRANIAL NERVES
Cranial Nerve I – Olfactory
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Cranial Nerve II - Optic

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Cranial Nerve III – Oculomotor

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Cranial Nerve IV- Trochlear

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 Cranial Nerve V – Trigeminal
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Cranial Nerve VI – Abducens

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Cranial Nerve VII – Facial

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Cranial Nerve VIII – Auditory

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Cranial Nerve IX – Glossopharyngeeal

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Cranial Nerve X – Vagus

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Cranial Nerve XI – Accessory

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Cranial Nerve XII – Hypoglossal

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g. Reflexes
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Biceps reflex
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Triceps reflex
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Brachioradialis reflex
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Patellar reflex
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Achilles reflex
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Plantar (Babinski’s) reflex

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XVII. Genitals and Inguinal Area

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XVIII. Rectum and Anus
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 ____________________________________________________________________________________
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XIX. Other Observations/Findings
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SUBITTED BY: _________________________________

SUBMITTED TO: ________________________________

DATE SUBMITTED:______________________________

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