UPT1 Physical Assessment Documentation Form 0414 1 
Health Assessment
Physical Assessment Documentation Form
Date: July 26, 2015
Patient Information
Patient Initials
CP
Age
25
Sex
M
General Survey
General Observations
Does patient appear to be their stated age?
No, patient stated a false age for student learning purposes.
Level of consciousness
Patient is Alert and oriented to person, place, and time.
Skin color
Skin color is appropriate for patient race.
Nutritional status
Well nourished
Posture and position
Appropriate position and posture for age
Obvious physical deformities
None noted
Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement
Appropriate gait
No use of assistive devices
ROM appropriate for BUE & BLE
No involuntary movement noted
Facial expression
Smiles, and uses appropriate gestures
Mood and affect
Pleasant and appropriate
Speech: articulation, pattern, content and appropriate, native language
Articulate speech, pattern, and content. Patient speaks native language of English
Hearing
Bilateral ears intact, hearing function normal
Personal hygiene
Appears clean, hygiene appropriate
Measurements and Vital Signs
Weight
195 lbs
Height
Not assessed, patient states 5’11”
BMI
27.2, overweight
Radial pulse: rate rhythm
70 rate regular Respirations: rate depth
16 breaths per minute regular, no SOB, or tachypnea noted
Blood pressure (indicate if sitting or lying)
Sitting
117/72
Temperature (if indicated)
Not assessed
Pain assessment
Not assessed (although no tenderness throughout)
Physical Assessment
Skin
Hands and nails
Appropriate color, equal size/shape, cap refill less than 3 seconds
Color and pigmentation
Appropriate color for patient race
Temperature
Warm
Moisture
dry
Texture
smooth
Turgor
Skin turgor appropriate for age, non-tenting
Presence of lesions? no lesions noted
Head and Face
Scalp
Hair
Cranium
Scalp dry and intact
Beginning of thinning hair
Cranium symmetrical
Face (cranial nerve VII)
Cranial nerve 7 intact, during
Physical Assessment Documentation Form
Date: July 26, 2015
Patient Information
Patient Initials
CP
Age
25
Sex
M
General Survey
General Observations
Does patient appear to be their stated age?
No, patient stated a false age for student learning purposes.
Level of consciousness
Patient is Alert and oriented to person, place, and time.
Skin color
Skin color is appropriate for patient race.
Nutritional status
Well nourished
Posture and position
Appropriate position and posture for age
Obvious physical deformities
None noted
Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement
Appropriate gait
No use of assistive devices
ROM appropriate for BUE & BLE
No involuntary movement noted
Facial expression
Smiles, and uses appropriate gestures
Mood and affect
Pleasant and appropriate
Speech: articulation, pattern, content and appropriate, native language
Articulate speech, pattern, and content. Patient speaks native language of English
Hearing
Bilateral ears intact, hearing function normal
Personal hygiene
Appears clean, hygiene appropriate
Measurements and Vital Signs
Weight
195 lbs
Height
Not assessed, patient states 5’11”
BMI
27.2, overweight
Radial pulse: rate rhythm
70 rate regular Respirations: rate depth
16 breaths per minute regular, no SOB, or tachypnea noted
Blood pressure (indicate if sitting or lying)
Sitting
117/72
Temperature (if indicated)
Not assessed
Pain assessment
Not assessed (although no tenderness throughout)
Physical Assessment
Skin
Hands and nails
Appropriate color, equal size/shape, cap refill less than 3 seconds
Color and pigmentation
Appropriate color for patient race
Temperature
Warm
Moisture
dry
Texture
smooth
Turgor
Skin turgor appropriate for age, non-tenting
Presence of lesions? no lesions noted
Head and Face
Scalp
Hair
Cranium
Scalp dry and intact
Beginning of thinning hair
Cranium symmetrical
Face (cranial nerve VII)
Cranial nerve 7 intact, during
References: Jarvis, C. (2008). Physical examination & health assessment (5th ed.). St. Louis, MO: Saunders/Elsevier.