Health Assessment
Physical Assessment Techniques Evaluation Form Assessment Area | Individual Items to AssessDemonstrate the correct technique for assessing the following: | Points/Points Possible | Measurement and Vital Signs | * The candidate asks the patient their weight. * The student takes the vital signs (pulse, respirations, and blood pressure). | /2 | Skin – | * Hands and nails * Color and pigmentation * Temperature
 * Moisture
 * Texture
 * Turgor
 * Any lesions | /7 | Head and Face | * Scalp, hair, cranium * Face (cranial nerve VII) * Temporal artery * Temporomandibular joint * Maxillary sinuses * Frontal sinuses | /6 | Eyes – describe in your video how you would use the ophthalmoscope to find the corneal light reflex. | * Visual fields (cranial nerve II) * Extraocular muscles (cranial nerves III, IV, VI) * Corneal light reflex * Cardinal positions of gaze * External structures * Conjunctivae * Pupils | /7 | Ears – Describe in your video how you would perform the Weber and Rinne tests for hearing. | * External ear * Any tenderness * Conduct the voice test (cranial nerve VIII) | /3 | Nose – Describe in your video how you would use a speculum to evaluate the nasal mucosa, septum and turbinates. | * External nose * Patency of nostrils
 | /2 | Mouth and Throat | * Lips and buccal mucosa * Teeth and gums * Tongue
Hard/soft palate * Tonsils
 * Uvula (cranial nerves IX, X) * Tongue (cranial nerve XII | /6 | Neck | * Symmetry, lumps, pulsations * Cervical lymph nodes * Carotid pulse (bruits if indicated) * Trachea * ROM and muscle strength (cranial nerve XI) * Thyroid gland | /6 | Posterior/Lateral Chest and Lungs | * Thoracic cage configuration a. Skin characteristics b. Symmetric expansion c. Tactile fremitus d. Lumps or tenderness * Spinous processes * Percussion over lung fields 
 * CVA tenderness * Breath sounds | /5 | Anterior Chest and Lungs | * Respirations and skin characteristics * Tactile fremitus, lumps, tenderness * Percuss lung fields
 * Breath sounds | /4 | Heart | * Precordium: pulsations and heave * Apical impulse * Precordium, thrills
 * Apical rate and rhythm * Heart sounds | /5 | Upper Extremities | * ROM and muscle strength * Epitrochlear nodes | /2 | Neck Vessels | * Jugular venous pulse * Presence of jugular venous distension | /2 | Abdomen | * Contour, symmetry, skin characteristics, umbilicus, and pulsations * Bowel sounds * Vascular sounds * Percussion * Liver span in right MCL
 * Spleen * Light and deep palpation
of liver, spleen, kidneys, aorta | /7 | Inguinal Area | * Femoral pulse * (both sides) Inguinal nodes | /2 | Lower Extremities | * Symmetry, skin characteristics, hair distribution * Pulses a. popliteal b. posterior tibial c. dorsalis pedis * Temperature, pretibial edema * Toes | /4 | Musculoskeletal/Neuro Balance | * Ankles and feet * Neurologic * Sensationa. face b. arms c. hands d. legse. feet * Position sense * Stereognosis * Cerebellar function (finger-to-nose) * Cerebellar function (heel-to-shin) * Bilateral deep tendon reflexes a. Biceps b. Triceps c. Brachioradialis d. Patellar Achilles * Babinski reflex | /9 | Hips/Knees ROM and Muscle Strength | * Walk across room (heel to toe) * Walk on tiptoes, then walk on heels * Romberg sign * Shallow knee bend * Touch toes * ROM of spine | /6 | Presentation | * Talks to patient * Explains procedure * Advises follow-up with primary care provider as needed * Thanks patient and leaves room | /3 | Total /88 |

Analysis of findings:
Note: You can add this to the end of this form or as a separate file attachment. The analysis portion of this task should be a 1-2 paragraph summary of your assessment findings. (What is your overall impression of the client’s health? Provide data/details to support your impression. Describe any abnormal findings? Can you correlate these findings to pertinent patient health history? Would you recommend follow up?) You can add this to the end of your health assessment documentation form or as a separate file attachment.
References/sources can be added to the end of this form or as a separate file attachment.