Learning Outcomes

After completing this chapter, you should be able to:

Identify the purposes and components of a physical
examination.
 Discuss the differences among a comprehensive,
focused, and ongoing physical examination.
Describe how to prepare for a physical examination.
Demonstrate the skills used in physical
examination.
 Identify the components of the general survey.
 Conduct a full physical examination of a client.
 Document the findings of a physical examination.
 Perform a brief bedside physical examination.
Definition:
Health assessment is the
systemic collection,
verification, organization,
interpretation and
documentation of data for use
by health care professionals.
Definition:
Health assessment is a
comprehensive assessment of
the physical, mental, spiritual,
socioeconomic, and cultural
status of an individual, group,
or community.
Medical assessments focus on

disease and pathology.

Nursing assessments focus on

the client’s functional abilities

& physical responses to illness
& other stressors.
 Purpose of assessment:
1. To establish a database about patient's
physical, psychological & emotional health.
2. Identify health promoting behaviors as well as
actual and /or potential problems.
3. Determines patient's abilities &/or
dysfunctions
4. To obtain data to establish medical diagnosis,
nursing diagnosis and plan patient's care.
5. To evaluate the physiologic outcomes of health
care & progress of patient's health problem.
 Type of
assessments
Comprehensive physical
assessment, which includes a
health history interview and
a complete head-to-toe
examination of every body
system.
A focused physical assessment

is performed to obtain data about

an actual, potential, or possible
problem that has been identified.
It pertains to a particular topic,
body part, or functional ability.
A system-specific assessment is

a focused assessment limited to

one body system (e.g., the lungs,
the peripheral circulation).
Equipment
1. Tuning Fork 14. Lubricant
2. Visual Occluder 15. Goniometer
3. Ruler 16. Clean Gloves
4. Visual Acuity 17. Cervical Spatula (Ayre
Chart Spatula)
5. Reflex Hammer 18. Cervical Brush
(brush at bottom) (Cytobrush)
6. Reflex Hammer 19. Cotton-tip Applicator
7. Pen and Marking 20. Tongue Depressor
Pen 21. Guaiac Material
8. Penlight 22. Tape Measure
9. Thermometer 23. Acoustic Stethoscope
10. 24. Ophthalmoscope
Sphygmomanometer 25. Otoscope with Speculum
11. Slide and Fixative 26. Objects for Neurological
12. Specimen Cup Examination (key & cotton
Techniques used for physical
examination:
Inspection [Look (inspect)].
Palpation. [Feel (palpation)].
Auscultation [Listen (auscultate)]
Percussion. [Tap or thump
(percuss)].
N.B: bilateral body parts are always compared
 Percussion
Use both hands to produce
sound waves.
Non dominant hand placed
directly on percussed area,
Middle finger placed firmly
on the body surface.
Other hand (dominant)
provides striking force,
initiated by a sharp downward
wrist movement.
 The five percussion tones are:
Tympany (‫ )طبلي‬- loud, drum-like sound

Resonance (‫ )رنين‬- moderate to loud, low-

pitch, hollow sound

Hyperresonance (‫)طنين‬- very loud, low-

pitch, booming sound

Flatness - soft, high-pitch, flat sound

Dullness - soft to moderate, high-pitch,

thud-like sound
 Palpation
Use dorsum of hand & fingers to measure

temperature.
Use palmer of fingers & finger pads to

assess texture, shape, fluid, size, consistency

and pulsation.
Light palpation: depress skin & underlying structures
½ inch ( ½’’ ) (1 cm).

Deep palpation: press inward about 1 inch (2.5 cm).

N.B: For palpating, the hands should be warm &

fingernails short. Any area of tenderness is

palpated last
Inspection
Inspect each area of the body for

size, color, shape, position, and

symmetry, noting normal findings
and any deviations from normal.
Auscultation:
Auscultation require the use of a

stethoscope to listen for heart

sounds, movement of bowel, lung
sounds.

1-Expose body part you want to

Auscultation:
2-Use stethoscope diaphragm to listen to pitched
sounds, (normal heart sounds, breath sounds, and
bowel sounds, and press diaphragm firmly on body
part being auscultated.

3-Use stethoscope bell to listen for low pitched

sounds, as abnormal heart sounds and bruits
abnormal loud, blowing, or murmur sounds.
Auscultation:
4-Hold bell lightly on auscultated body part.

5-Identify detected sounds using auscultation arc

classified according to the:

 Intensity ‫( ا لشدة‬loud or soft),

 Pitch ‫( ا لدرجة‬high or low),

 Duration (length), and Quality

 I. Patient's preparation:
 Explain procedure to patient, examined body

structures, & assessments painless.

 Ask the patient to wear a gown.

 Ask to empty bladder to be more comfortable

 Answer questions directly and honestly.

 Avoid undesirable nonverbal communication

 Keep patient warm. Provide a lightweight blanket.

 I. Patient's preparation:
 Keep your hand smooth.

 Choose assessment time, patient free of

pain as possible, not interfere with meals,

daily routines, treatment or visiting hours.
 Keep necessary instruments & equipment

assembled, and ready for use.

Environmental preparation:
 Provide clean, well ventilated,
quite and private environment.
 Warm instruments; for example,

warm bell of stethoscope by

rubbing it between your hands
before placing it on a patient.
Positioning
 Use to
assess vital
Sitting signs, head
& neck,
chest,
cardiovascul
ar system, &
breasts.
Use to assess
the abdomen,
Supine breasts,
extremities,
and pulses.
 Use for
abdominal
Dorsal assessment if
Recumbe your client
nt has abdominal
or pelvic pain.
Flexing the
knees
promotes
relaxation
Use for a
female pelvic
Lithotomy exam; provides
maximum
exposure of
genitals.
 Use to
examine the
rectal area.
Sims’ Use for a
female pelvic
exam if the
patient is
unable to
assume the
lithotomy
position.
Use to examine
the
musculoskelet
Prone al system,
especially hip
 Left lateral
recumbent is
used to
Lateral evaluate heart
Recumben murmur or
t during a
thorough
cardiovascular
assessment.
Provides good
visualization for
Knee– examining the
Chest rectal area.
 2- Health history
a- Chief Complaint:
1.Description of major problem
2.Location: "Where does it hurt?"
3.Quality: “What does it looks like?“
4.Quantity: "on a scale of one to ten with ten
most severe.
5.Chronology: symptom in relation to time;
Begin gradually or suddenly? Stay the same
in quality & intensity?
6.Aggravating or alleviating factors:
7.Associated factors: Assess the associated
factors of symptoms.
COLOR DESCRIPTION
VARIATIO
N
Pallor White in light-skinned clients:
loss of pink or yellow tones. In
dark-skinned clients: a loss of
red tones
Cyanosis A blue-gray coloration of skin,
(ashen)
Jaundice A yellow-orange cast to the skin
Flushing A widespread, diffuse area of
redness
Erythema A reddened area
 Past health history
Previous disorders & contacts with
health care setting and professionals.
Pediatric and adult illness

Operations and injuries

Allergies or sensitivities.

Current medications.
Previous hospitalization & its reason.

Transfusions.
Family health History:
Present health
status of parents &
siblings for: medical
problems, similar
illness or symptoms
in family.
 Systems review
General appearance and
functional abilities
Condition of hair:
Normal amount &
distribution
Healthy looking or brittle

Baldness  natural or due

to illness
Grooming  clean, tidy,

presence of lice nits or

dandruff.
Condition of the scalp:
Intact

Presence of scratches,
lacerations infected areas
nodules or circumscribed
alopecia.
 Condition of face
 Pale, flushed, mottled, cyanosed or jaundiced

 Presence of swelling, abrasions, contusions,

lacerations or scars
 Presence of tingling, numbness, burning, loss

of sensation or muscles twitching

 Paralysis of facial muscle, (facial palsy).
 Condition of eye:
 Sight  normal, impaired sight,

wears glasses, squinting & loss of

eyes blindness

 Eyelids  scaly eyelids, redness of

lids, puffiness of lids or dropping of

lids

 Ecchymosis of eyes, redness,

jaundiced eyes, excessive tearing

or discharge

 Eye Ball  bulging or sunken.

 Condition of ears:
 Inspect external ear for intactness, general
hygiene, a buildup of wax, discharge, redness,
and swelling.

* If discharge, note color, amount, consistency &

clarity.
 Palpate external ear for nodules & tenderness

and mastoid process for tenderness.

 Complains of pain  indicates external ear
infection.
Auditory acuity
Watch test:
 Instruct patient to occlude one ear, move watch

toward other.
 Determine distance when patient hears watch, test

both ears.

Whisper test:
Instruct to occlude one ear, stand 1-2 feet away

from patient.

 Weber lateralization test:
 Place stem of the vibrating

tuning fork in the center of

the forehead.
 Ask patient where sound is

heard well.
 Note if hearing was better in

one side
N.B: than the
Normally, other.
sound is heard equally well in
both ears as it is conducted though bones.
Rinne air & bone conduction test:
Place stem of tuning fork on mastoid process behind ear

Move quickly fork beside ear canal as soon as patient says

the sound is gone from contact with the mastoid bone.

N.B: Normally sound is heard twice as long by air

conduction as by bone conduction.
Condition of nose
Inspect deformed, edematous or inflamed nares

Observe discharge from nose running nose,

mucus, bloody or purulent

Assess impaired sense of smell

Assess nasal breathing difficulty

 Condition of mouth
Lips pale, cyanosed, dry,

cracked, inflamed, presence

of herpes or deformities.
Tongue  pale, brown,
coated, patched, ulcers,
cracked or loss of taste.
Gums pale, edematous,
bleeding. Inflamed or pussy
discharge.
 . Condition of mouth cont
Breathe  foul, ammonia, alcoholic or

acetone.
Teeth healthy, missing, broken, loose,

decayed or stained, poor oral hygiene, use

of denture (partial or complete).
Abnormality of the jaws  deformity or

due to surgery.
Has difficulty of speech  aphasia, route
 Condition of neck
 Inspect color, symmetry, thyroid
gland enlargement, abnormal
pulsations, lymph nodes masses,
impaired ROM, lesions, scars.
 Palpate for temperature & texture.

 Instruct to move neck through full

ROM.
 Palpate carotid rate & rhythm,

pulsation
 Ask patient to shrug shoulders
Condition of the chest, lung & heart
I. Posterior chest:
Inspect: skeletal deformities that could affect

respiratory system
Common abnormalities are kyphosis,
scoliosis & lordosis.
Palpate: For tenderness & masses.

Auscultation: to assess air flow, presence of

fluid, mucus or obstruction.

Condition of the chest, lung & heart
II. Anterior chest:
Inspect: For any skeletal deformities which

are barrel chest (horizontal ribs, slight

kyphosis, & prominent sternal angle),
pigeon chest (forward projection of
sternum), & funnel chest (sternum pointing
posteriorly).
Palpate: For tenderness.
Heart:

Auscultate apical pulse which is

situated between 5th & 6th

intercostal spaces.
Assess rate and rhythm.
Condition of the
Abdomen
Vital signs
1) Body temperature:
Range ( OC).

Site oral, axillary, tympanic or

rectal.
Presence of abnormality
hyperthermia, hypothermia.
Pattern of fever  constant,
intermittent or remittent.
Respiratory status
Rate / minute (c/m)

Depth deep or shallow

Rhythmregular or irregular.

Presence of difficulty dyspnea,

orthopnea.
Use of oxygen therapy.

Interference with normal breathing,

cough, sputum or chest pain
Pulse status
Site  peripheral or apical.

Rate beat/minute (b/m).

Rhythm regular or irregular.

Strength  strong or weak.

Volume  full or thready.

Blood pressure status

Blood pressure reading 

Systolic & diastolic
Pulse pressure.
 0 indicates no pain.
Pain assessment From 1 < 3 mild pain.
From 3< 6 moderate.
Radiation  (back radiation)
From 6 – 9 severe.
Duration (time of pain) 10 very severe pain.
Severity  (mild- moderate - sever)
Site  (upper outer quadrant of the

abdomen)
Frequency  (the repetition of pain attack)
Aggravating factors  (factors causing pain)
Alleviating factors  (factors causing relieve
 Reflexes
Deep tendon reflexes
Each tendon reflex utilizes certain
spinal segments and help in utilizing a
lesion
Biceps & Brachioradialis reflex
Superficial
Triceps reflex Reflexes

Knee Jerk reflex Corneal reflex

Planter reflex
 Ankle reflex
I Deep reflexes
 Are elicited by applying a sudden stretch to
the muscles by a sharp tap from a tendon
hammer near the insertion of the tendon.

Brachioradialis reflex
 Flex client’s arm 45° and

place in lap with the arm in

semipronation. Tap
brachioradialis tendon on
thumb side of wrist
Biceps reflex
Bend the arm at the elbow (flexion), with the

palm up supination)
Support the length of the arm by holding it or

resting it on a flat surface.

Place thumb against tendon; striking thumb

with a reflex hammer thereby stretching

underling tendon.
 Triceps reflex
Flex patient's arm at elbow & positioned in front of

chest.
Support patient's arm & identifies triceps tendon by

palpating 2.5 to 5 cm above the elbow.

A direct blow on the tendon normally produces.
Knee jerk (patellar reflex Or
quadriceps reflex)
 Strike patellar tendon just

below the patella.

 Support legs to facilitate
relaxation of muscles. If
patient is supine. Or
 Ask the patient to sit on the edge of a high

bed or chair with the legs hanging freely.

5) Ankle jerk or Achilles tendon reflex

Grasp the foot by

dorsiflexed and
erected with hip
and knee joints
partially flexed.
II Superficial reflexes
A) Corneal reflex:
Wisp of cotton-wool with light down of
cornea, while the cotton-wool is out of
sight of the patient.
 Planter reflex:
 Ask patient to lye on his back & his knees extend

blunt object (as a key) is stroke along the outer

border of foot sole from heel upwards towards the
toes an then across inwards across transverse arch.
 Abnormal response results in fanning of the

toes which is known as Babinski's sign.

Nutritional
assessmen
t
 II. Clinical
III.
observation
Anthropometric
Signs of good( Measurements
)nutrition

I.
Assessment IV.
of food Laboratory
intake Nutrition Analysis
.patterns al
assessme
nt
I. Assessment of food intake patterns
Dietary history and health history:
Identify patient's habitual intake of foods and liquids.

Identify preferences, allergies and patient's ability to obtain food.

Determine number of meals & snacks eaten each day, types & amount

of food eaten, food omitted and reasons & methods of food preparation.
Assess patient's illness, activity level to determine energy needs and

compares food intake.

Assess health status, age, culture background, religious food patterns,

socioeconomic status, psychological factors, use of alcohol or illegal

drugs, use of vitamins, minerals, or herbal supplements, prescription or
over -the -counter drugs (OTC).
 II. Clinical observation
Signs of good nutrition
 Assess clinical observations of nutritional status;

clues to malnutrition may be observed during

physical assessment
 Assess patient's risk of aspiration, as patients

with  level of alertness,  gag, &/or cough

reflexes & patients who have difficulty managing
saliva.
 Check patient's adequacy of swallow; before giving

food or medications by placing fingers at level of

Clinical signs of
good nutrition
Clinical signs of good nutrition Body area
- Alert responsive. 1- General appearance.
- Normal weight to height, age, body builds. 2- Weight.
- Erect posture; straight arms and legs. 3- Posture.
- Well developed, firm muscles, good tone, some fat under the skin. 4- Muscles.
- Good attention span, lack of irritability, normal reflexes. 5- Nervous system control.
- Good appetite, and digestion, regular elimination, no palpable organ. 6- Gastrointestinal function.
- Normal heart rate and rhythm, normal B.P, lack of murmurs. 7- Cardiovascular function.
- Energy, good sleep habits. 8- General vitality.
- Shiny, firmness, not easy plucked, healthy scalp. 9- Hair.
- Smooth and slightly moist, with good colour. 10- Skin.
- Uniform color, smooth, pink, healthy appearance, lack of swelling. 11- Face and neck.
- Smoothness, good colour, moist (not chapped or swollen) appearance. 12- Lips.
- Reddish pink mucous membranes in oral cavity. 13- Mouth, oral membrane.
- Good pink color, healthy red appearance, lack of bleeding or swelling. 14- Gums.
- Good pink or deep reddish color, lack of bleeding, lesions or swelling, 15- Tongue.
- Lack of cavities and pain, bright, straight appearance, lack of crowding. 16- Teeth.
- Bright clear, shiny appearance, lack of sores at corner of membranes. 17- Eyes.
- Lack of enlargement. 18- Neck (glands).
- Firm, pink appearance. 19- Nails.
- Lack of tenderness, weakness or swelling. 20- Legs, feet.
- Lack of malformation. 21- Skeleton.
III. Anthropometric measurements
Obtained height & weight for each patient

on admission. If possible weight at the

same time each day, in same scale & with
same cloth or linen.
Assess any rapid weight gain (reflects fluid

shifts).
Compare height and weight to standards

for weight – height relationships.

III. Anthropometric measurements
Measure mid–upper arm
circumference, triceps skin fold &
mid–upper arm muscle
circumference.
Calculation of BMI is achieved by

dividing weight in kilograms by

height in meters squared:
III. Anthropometric measurements
Underweight  BMI less than 18.5

Normal weight 18.6 and 24.9

Overweight  BMI of 25 to 29;

Obese  BMI of 30 or more.

BMI of > 35 places a patient at

higher medical risk of coronary heart

disease, some cancers, diabetes
III. Anthropometric measurements
If the height cannot be
measured with the patient
standing position the patient lying
flat in bed as straight as possible,
arms folded on the patient's chest
and measure the patient
lengthwise.
IV. Laboratory
analysis and
biological tests
 Common laboratory tests used to study
nutritional status
1- Plasma proteins:
Albumin, transferring.
Prealbuimin.
Hemoglobin.
Hematocrit.
Blood urea.
Cretinine.
Blood urea nitrogen, blood sugar
level, minerals and vitamins levels
and specific gravity of urine.
Serum Albumin Level
It is a better indicator for
chronic illnesses.
It is affected by the following
factors: hydration,
hemorrhage, renal or
hepatic disease, high
output drainage of wound,
drains, burn, steroid
administration, exogenous
albumin transfusion, age,
trauma, stress, or surgery.
2- Nitrogen balance
 The output of nitrogen is established
through laboratory analysis of 24 hours
urinary urea nitrogen (UUN).
 By contrast, negative nitrogen balance
when catabolic exists, seen in either
starvation or physiological stress.
- Student's name: - Group:
- Section: - Date of assessment:
Patient's History and Physical Assessment Guideline Sheet
1- Patiental or social history:
Patient's name. …………………………………………………………………..
Age. ………………………………………………………………………………...

Sex. - Male. ( ) - Female. ( )

Education
- Illiterate. ( ) - Primary. ( ) -Preparatory ( ) -Secondary - University. ( )
( )
Marital status.
- Single. ( ) - Married. ( ) - Widow. ( ) - Divorced. ( ) - Single. ( )
Occupation
- Manual. ( ) Professional( ) Housewife. ( ) - Not work. ( )
 Area of residence. - Urban. ( ) - Rural. ( )
Previous hospitalization. - Yes. ( ) - No. ( )
Pattern of admission.
- Private physician ( ) - Outpatient clinic ( ) - Emergency unit ( )
General Condition.
- Active. ( ) - Weak. ( ) - Bed ridden. ( ) Obese. ( ) - Well nourished.( )

2- Health history
a- Chief Complaint:
------------------------------------------------------------------------------------------------------------
- Location: ---------------------------------------------------------------------------------------------
- Quality: -----------------------------------------------------------------------------------------------
- Quantity: ---------------------------------------------------------------------------------------------
- Chronology: -----------------------------------------------------------------------------------------
- Aggravating or alleviating factors: -------------------------------------------------------------
- Associated factors: ---------------------------------------------------------------------------------
3- Past health history:
Pediatric and adult illness.
------------------------------------------------------------------------------------------------------------
Previous hospitalization and the reason for it.
--------------------------------------------------------------------------------------------------------
Operations and injuries.
--------------------------------------------------------------------------------------------------------
Immunizations.
--------------------------------------------------------------------------------------------------------
Allergies or sensitivities.
--------------------------------------------------------------------------------------------------------
Transfusions.
--------------------------------------------------------------------------------------------------------
Current medications.
--------------------------------------------------------------------------------------------------------
Current treatments.
--------------------------------------------------------------------------------------------------------
4- Family health History:
---------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------
Systems review
General appearance and
functional abilities
Condition of hair: Yes No
Normal amount and distribution ( ) ( )
Healthy looking or brittle ( ) ( )
Baldness  natural or due to illness ( ) ( )
Grooming  clean, tidy, presence of lice nits or dandruff. ( ) ( )
Condition of the scalp:
Intact
( ) ( )
Presence of scratches, lacerations infected areas nodules or circumscribed alopecia. ( ) ( )
Condition of face:
Pale, flushed, mottled, cyanosed or jaundiced ( ) ( )
Presence of swelling, abrasions, contusions, lacerations or scars ( ) ( )
Presence of tingling, numbness, burning, loss of sensation or muscles twitching ( ) ( )
Paralysis of facial muscle, (facial palsy). ( ) ( )

Condition of eye:
Sight  normal sight, impaired sight, wears glasses, squinting, and loss of eyes blindness ( ) ( )
Eyelids  scaly eyelids, redness of lids, puffiness of lids or dropping of lids ( ) ( )
Ecchymosis of eyes, redness of eyes, jaundiced eyes, excessive tearing or discharge ( ) ( )
Eye Ball  bulging or sunken. ( ) ( )
( ) ( )
Pupils  regular, equal or not equal
( ) ( )
Blurring of vision or pain in the eye.

Condition of ears:
Symmetrical in size, absent or deformed ( ) ( )
Swelling around the ear ( ) ( )
Discharge from me ear  bloody, purulent or wax ( ) ( )
Impaired hearing  Partial or complete, unilateral or bilateral ( ) ( )
Use of hearing aid ( ) ( )
( ) ( )
Abnormal sensation  Tenitus, pain, tenderness, itching or vertigo
Whisper test: -
Positive: ( ) - Negative: ( )

Rinneair and bone conduction test:

Positive: ( ) - Negative: ( )
Condition of nose: Yes No
Deformed, edematous or inflamed nares ( ) ( )
Discharge from the nose running nose , mucus, bloody or purulent ( ) ( )
Impaired sense of smell ( ) ( )
Difficulty of nasal breathing. ( ) ( )
Condition of mouth:
Lipspale, cyanosed, dry, cracked, inflamed, presence of herpes or deformities.
Tongue  pale, brown, coated, patched, ulcers, cracked or loss of taste. ( ) ( )
Gums  pale, edematous, bleeding. Inflamed or pussy discharge. ( ) ( )
Teeth healthy, missing broken, loose, decayed or stained, poor oral hygiene, use of denture (partial or ( ) ( )
complete). ( ) ( )
Breath  foul, ammonicaL alcoholic or acetone. ( ) ( )
Abnormality of the jaws deformity or due to surgery. ( ) ( )
Has difficulty of speech  aphasia, route or unusual speech manner. ( ) ( )
Condition of neck:
Swelling of the neck  anterior posterior. Unilateral or bilateral. ( )
Presence of old scare. ( ) ( )
Limitation of movements (R.O.M). ( ) ( )
( )
Condition of the chest, lung and heart:
I. Posterior chest:
- Skeletal deformities that could affect the respiratory system Common abnormalities are kyphosis, ( ) ( )
scoliosis and lordosis. ( ) ( )
- Tenderness and masses. ( ) ( )
- Air flow, presence of fluid, mucus or obstruction. ( ) ( )
II. Anterior chest: Yes No
- Skeletal deformities which are barrel chest horizontal ribs, slight kyphosis, and prominent sternal angle. ( ) ( )
- Pigeon chest forward projection of the sternum. ( ) ( )
- Funnel chest sternum pointing posteriorly and tenderness. ( ) ( )

Heart:
Apical pulse Assess rate and rhythm. ( ) ( )
Abnormal heart sounds. ( ) ( )
1) Body temperature
Range =
Site =
Presence of abnormality:
Pattern of fever:
2) Respiratory status
Rate =
Depth: deep or shallow
Rhythm: regular or irregular.
Presence of difficulties: dyspnea or orthopnea.
Use of oxygen therapy:
Interference with normal breathing: cough, sputum or chest pain
3) Pulse status
Site: peripheral or apical.
Rate =
Rhythm: regular or irregular.
Strength: strong or weak.
Volume: full or thready.
Apical pulse =
4) Blood pressure status
Blood pressure reading =
Pulse pressure =
Site:
Patient's position:
Pain assessment:
Site: Radiation:
Severity: Duration:
Frequency:
Aggravating factors:
Alleviating factors:
Pain rating scale from zero to ten.
 Reflexes
I. Deep tendon reflexes
- Biceps & Brachioradialis reflex - Positive: ( ) - Negative: ( )
- Triceps reflex - Positive: ( ) - Negative: ( )
- Knee Jerk reflex - Positive: ( ) - Negative: ( )
- Ankle reflex - Positive: ( ) - Negative: ( )

II. Superficial Reflexes

- Corneal reflex - Positive: ( ) - Negative: ( )
- Planter reflex - Positive: ( ) - Negative: ( )
 Nutritional assessment
Body weight /kg =
Body height /cm =
Body Mass Index (BMI) =
Yes No
Ability to masticate: Chews with eases or has difficulty. ( ) ( )
Ability to swallow: Swallows with ease or has dysphasia. ( ) ( )
Appetite: Good appetite, anorexia or polyphagia. ( ) ( )
Rout of food intake by:
( ) ( )
- Mouth, Intravenous (I.V). ( ) ( )
- Nasogastric tube (NGT) ( ) ( )
- Gastrsatomy tube.
- Type of therapeutic diet:
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- Likes and dislikes:
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- Degree of help needed during eating:
- Independent ( ), minimal ( ) or complete help ( ).
- Presence of nausea: before ( ) or after meals ( ).
- Duration and frequency:
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Presence of vomiting: ( )
- Character of vomitus: -----------------------------------------------------------------
- Amount: -------------------------------------------------------------------------------------------
- Consistency: --------------------------------------------------------------------------------
- Frequency: --------------------------------------------------------------------------------------
- Odour: ----------------------------------------------------------------------------------------------------------
- Liquid or solid: ------------------------------------------------------------------------------------------------
- Precipitating factors: ------------------------------------------------------------------------------------------
- Association with meals or not related to meal and odour: -----------------------------------------------