When a patient seeks medical checkup or sees a doctor, nurse or a physician, it is important to carry out a physical condition assessment so as to establish their physical health status. The physical assessment form is used in such a situation. The form is often filled before seeking medical treatment, before undertaking vigorous physical activity or seeking a physically demanding job. Here is a sample physical assessment form.
PHYSICAL ASSESSMENT FORM
(This form should be filled completely by a nurse, doctor, physician or a medical practitioner or their assistants.)
Date: _________________
Patient Details
Name: ______________________________ Age: _______ Date of Birth: ___________
Address: ________________________________ State: ___________ Zip: ___________
Phone: _______________________________ Email: ____________________________
Health condition
Height: __________ Weight: ___________
Vision: Left: _____/_____ uncorrected /corrected ________________________________
Right: _____/_____ uncorrected /corrected ________________________________
Glasses __________________ Contacts __________________
Blood pressure _____/_____ Pulse ___________________ Hearing __________
Body part Normal Abnormal Comment
Mouth, Throat and Teeth __________ __________ ______________________
Eyes, Nose and Ears __________ __________ ______________________
Thyroid and Neck __________ __________ ______________________
Cardiovascular __________ __________ ______________________
Lungs and Chest __________ __________ ______________________
Abdomen __________ __________ ______________________
Skin __________ __________ ______________________
Genitalia __________ __________ ______________________
Musculoskeletal
Neck, Shoulders and arms __________ __________ ______________________
Hands, hips and back __________ __________ ______________________
Feet, knees and legs __________ __________ ______________________
Neurological __________ __________ ______________________
Women only (If applicable)
Date of last gynecological exam ________________________
Pap smear date _____________________________________ Result: ________________
Breast Exam date ___________________________________ Result: ________________
Please comment on whether further evaluation or care is needed
Does the patient smoke cigarettes? ______________________ for how long? ________
Does the patient drink Alcohol? _________________________ for how long? ________
Assessor name ________________________________ Position: ____________________
Signature: ____________________________________ Date: _______________________
Print This Post