DATE          TIME (24hr) 
Examiner:          Subject Code: 

VITAL SIGNS:
Temperature: tympanic    oral   
Height: cms       Weight: kgs
Resp. Rate: per min.
Pulse supine (e.g., taken for 15 seconds x 4):        Blood pressure:
Pulse standing (for 30 seconds):        Blood pressure:
Pulse standing (for 1 minute):        Blood pressure:
Pulse sitting (for 1 minute):        Blood pressure:

1. APPEARANCE:
       Normal (WDWN)
       Obese        Morbidly obese        Slight        Cachectic
        

1a. GENERAL DRESS:
       Normal (Appropriately dressed for circumstance)
       Unkempt        Disheveled        Other
        

2. ASSISTIVE DEVICES:
       None
       Cane/crutch        Brace/Splint        Hearing aid        Glasses
        

3. HEAD:
       Normal (atraumatic)
       traumatic deformity        other
        

4. Eyes:
       Normal (sclera are white)
       Abnormal
        

5. EARS:
       Normal (canals are clear, TMs intact bilaterally, finger rubbing heard at 10cm)
       Abnormal
             Canal-R:    Normal:    Abnormal
    Canal-L:    Normal:     Abnormal
    Tympanic membrane-R:   Normal:     Abnormal
    Tympanic membrane-L:   Normal:     Abnormal
        

6. NOSE:
       Normal (Septum midline)           abnormal
    Mucosa:   Normal:      Abnormal
        

7. MOUTH, THROAT:
       Normal: (Full ROM, no nodes or masses noted, thyroid palpation normal. Dentition is non-acute, oropharynx is pink, tongue is midline)
       Abnormal
        

8. NECK:
       Normal: (Full ROM, no nodes or masses noted, thyroid palpation normal)
       Abnormal
  Nuchal rigidity:    no, yes
    Carotid bruits:
        Left:   absent    Present
        Right: absent     Present
    Jugular Venous Distension   no:      yes
        

9. LUNGS:
       Normal (Lungs clear to auscultation in all lobes)
       Abnormal
         Excursion:   Normal:      Abnormal
        

10. HEART:
       Normal (NSR, normal S1-S2 without rubs, murmurs)
       Abnormal
    Rate:   Normal:     Slow     Rapid
    Rhythm:   Regular      Irregular
    Heart Sounds:   Normal:      Abnormal
    Murmurs:   Absent:      Present
    Gallops:   Absent      Present
    Rubs:   Absent      Present
        

11. ABDOMEN:
       Normal (Bowel sounds normal, abdomen soft, no tenderness, guarding)
       Normal (Bowel sounds normal, abdomen soft, no tenderness, guarding, liver at CM, spleen not palpable, no tympany or hernia)
       Abnormal
    Bowel Sounds:   Normal:      Hyperactive     Hypoactive
    Palpation: soft, non-tender:      Abnormal
    Hepatosplenomegaly;absent:     present
        

12. RECTAL/PELVIC:
       Normal (no lesions noted, no fissuers, prostate soft, without nodules)
       Not indicated
       Declined
       Abnormal
        

13. EXTREMITIES:
       Normal (no abnormalities noted noted)
       Abnormal
    Amputation:
        LUE:  No:     Yes     
        RUE:  No:     Yes     
        LLE:  No:     Yes     
        RLE:  No:     Yes     
    Appearance:   Normal:      Abnormal     
    Pulses:  Normal:     Abnormal     
    Edema:  absent:     Present         
        

14. MUSKULOSKELETAL:
       Normal (no abnormalities noted noted)
       Abnormal
       Normal:     Abnormal
    Cervical spine:  FROM:     Abnormal ROM:     
    T/L/S spine:   Normal curvature:     Scoliosis:   Kyphosis:     
    L/S spine:   FROM:     Abnormal ROM:
         Positive SLR - Right:    Positive SLR - Left:     
    Upper extremities:
        Shoulders:     FROM     Abnormal ROM:      Right     Left:
                 Pain-free motion     Pain on ROM:      Right     Left:
                 Other comments:
        Elbows:     FROM     Abnormal ROM:      Right     Left:
                 Pain-free motion     Pain on ROM:      Right     Left:
                 Other comments:
        Wrists; hands:     FROM     Abnormal ROM:      Right     Left:
                 Pain-free motion     Pain on ROM:      Right     Left:
                 Other comments:
    Lower extremities:
        Hips:     FROM     Abnormal ROM:      Right     Left:
                 Pain-free motion     Pain on ROM:      Right     Left:
                 Other comments:
        Knees:     FROM     Abnormal ROM:      Right     Left:
                 Pain-free motion     Pain on ROM:      Right     Left:
                 Other comments:
        Ankles:     FROM     Abnormal ROM:      Right     Left:
                 Pain-free motion     Pain on ROM:      Right     Left:
                 Other comments:
        feet; hands:     FROM     Abnormal ROM:      Right     Left:
                 Pain-free motion     Pain on ROM:      Right     Left:
                 Other comments:
        

15. SKIN:
       Normal (no abnormalities including rashes, lesions, ulcers, infections noted)
       Abnormal
     Normal:      rashes:     
    Scars:   normal:      other
        

16. LYMPHADENOPATHY:
       Normal (no lymphadenopathy noted)
       Present
         present?   (check below)
        cervical:    supraclavicular:     axillary:     inguinal:     other:
        

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