Date and Time of Assessment:

PATIENT'S NAME:
AGE:
ADDRESS:
CHIEF COMPLAINT:

GENERAL SURVEY: Patient is alert, oriented to person, place and time. Speech is clear and coherent.
Dress is appropriate, with good hygiene and well-groomed. Patient is cooperative and exhibits pleasant
calm behavior .

VITAL SIGNS
T:
P:
R:
BP:

HT (CM):
WT (KG):

SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS

Skin No known history of Skin color is uniform all No abnormalities noted
allergies and other skin over the body with
conditions good skin turgor. No
lesions, edema and skin
discharges noted.
No foul odor observed.
Temperature is within
normal limits.

Nails No known history of Fingernail and toenails No abnormalities noted

nail clubbing and nail are intact and in pinkish
discoloration color with nail plate
angle of approximately
160 degrees. Nails are
smooth and even. With
good capillary refill of
less than 5 seconds.

SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS

Hair and Scalp No known history of Smooth and silky is No abnormalities noted
hair loss and presence evenly distributed.
of parasites on the Scalp has a lighter color
head. than the skin color.
 Presence of lesions, lice
and other infections not
noted

SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS

Head No known history of  Head is round, No abnormalities noted
stroke, headaches, symmetrical, erect,
dizziness and head and in midline and is
injury. appropriate to body
size. No lesions noted
 Upright and no
involuntary
movements noted.
No report of
tenderness on
temporal artery and
TMJ area.
 Mouth opens and
closes fully and lower
jaw moves lateral in
each other

SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS

Neck No known history of  Neck's size and No abnormalities noted
swallowing difficulties. length is symmetric
No known history of and in the midline
changes in appetite. without tenderness
and bulging.
 Difficulty in
swallowing not
noted.
 There were no
limitations during
movement.
 Cervical vertebrae
in normal condition
with C7 visible and
palpable.
 Trachea is in
midline.
 Range of motion of
the neck is smooth
and controlled.
 The glandular
thyroid tissue was
felt rising
 underneath and the
lobes feel smooth,
rubbery, and also
free of any
tenderness,
swelling, or nodules.

SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS

Eyes No new onset of  Client has normal No abnormal findings
headaches, dizziness, vision, 20/20 on noted.
and other visual both eyes on
disturbances. No history Snellen chart
of visual loss and no  Able to identify
history of eye surgery. letter/read in the
No history of seeing newsprints at a
floaters, flashing lights distance of fourteen
and halos around lights. inches.
 No signs of eye
movement during
cover test.
 The lights reflection
on the corneas are
in the same spot
 Eyelashes are
equally distributed
and curled
outwards
 Eyelids' skin are
intact with no
discharges and no
discoloration. Lids
close symmetrically
and blinks
involuntary.
 Pupils are round,
equal and reactive
to light with intact
accommodation
SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS
Nose and Sinuses No known allergies and  Nose is in the No abnormal findings
smelling difficulties midline of the face, note
with normal
appearance and no
purulent discharges.
 Able to sniff
through each
 nostril.
 Nasal flaring not
noted during
breathing.
 Nasal congestion
not noted. No
airflow obstruction
noted.
 Tenderness and
inflammation upon
palpation on the
sinuses not noted
SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS
Mouth and Throat No known history of  Lips are smooth No abnormalities noted
gum bleeding. No and no cracking
changes in eating present.
patterns as claimed. No  Oral mucosa is
report of loose of teeth moist and pinkish
or sensitive teeth. in color.
 Redness, swelling
and lesions not
noted. Stensen's
duct visible
without redness.
 Frenulum is in
midline.Equal
bilateral strength
of the tongue
noted, smooth,
pinkish with small
visible veins
present
 Soft palate smooth
and pink.
 Tonsillar pillars
pink and
symmetric.

SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS

Ears No known history of  Ears are equal in size No abnormalities noted
hearing problems and bilaterally.
balance problems.  Auricles are aligned
with the corner in
each eye. Skin is
smooth, no lumps,
lesions , nodules.
 Non tender on
palpation. Small
amount of moist,
yellow cerumen in
external canal.
 Whisper test: patient
reports 2 syllable
word.
 Vibration felt on
both ears during
Weber Test
 Air conduction is
longer than bone
conduction during
Rinne Test
 Patient
demonstrates good
balance and a
coordinated gait.
SYSTEM HEALTH HISTORY NORMAL FINDINGS ABNORMAL FINDINGS
Thorax and Lungs No known history of Respiration is 18 cycles No abnormalities noted
asthma and other per minute, relaxed and
breathing problems. No even. Anteroposterior
reports of chest pains. less than traverse
Do not use cigarettes or diameter. Chest
vape as claimed. expansion symmetric.
No retraction or bulging
of intercostal spaces.
No pain or tenderness
on palpation. Tactile
fremitus symmetric.
Percussion tones
resonant all over the
lung fields. vesicular
sounds auscultated
over lung fields. No
adventitious sounds
present.