Complete Physical Examination Eform

Complete Physical Examination eForm Page 1

Patient demographic labelExamining Physician Date of examination

Problem List

Abbreviations:N/E = Not examined Pres = Present Abs = Absent Nor= Normal Abn = Abnormal

Height M; Weight Kg BMI Waist cms.

General appearance:

Head / Right / Left
N/E / Nor / Abn - Comment / N/E / Nor / Abn - Comment
Ear Canals
Ear Drums
Eye lids
Conjunctiva
Pupils …….
…….Reflexes
Lenses
Retinae
Movement
Scalp
Hair
Nevi

Other comment:

Hearing Threshold dB N/E : or
500Hz / 1 KHz / 2 KHz / 4KHz
Right
Left
Visual Acuity N/E : or
Uncorrected / OD / OS / OU
Corrected / OD / OS / OU

Hearing Aid(s) worn: Glasses Contacts

Colour vision: N/E Ishihara Other : # of errors Visual fields: N/E Nor Abn

Nose / N/E / Nor / Abn
Septum
Mucosa

Other

comment

Oral Hygiene: Good Fair Poor Edentulous Dentures – Upper Lower

Buccal cavity / N/E / Nor / Abn - Comment
Palates
Fauces
Salivary glands
Tongue
Mucosa

Other

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Complete Physical Examination eForm Patient Name: Date Page 2

Neck / N/E / Nor / Abn - Comment
Lymphatics
Thyroid
JVP
Carotids
Trachea / Undisplaced Displaced
Other

Cardiovascular Blood Pressure:Supine Sitting Standing

Pulse /min. Rhythm Regular ; or

Irregular (describe)

Heart / N/E / Nor / Abn Describe
Apex
S1
S2
Abs / Pre / Describe
S3
S4
Murmur

Abdominal aorta Bruit Absent Present Pulsatile mass Absent Present Size cms

Pulses palpable / Right / Left
Femoral
Popliteal
Posterior tibia
Dorsal pedal

Carotid bruit NE Right Absent Present Left Absent Present

Hallux capillary refill time N/E Right secs Left secs

Veins:Normal or Varicosities: Mild Moderate Severe

Other

Comment:

Upper Body

Breasts / N/E / Nor / Abn Describe
Skin
Nipples
Parenchyma
Rt axilla
Lt axilla
Rt shoulder
Lt shoulder
Rt elbow
Lt elbow
Rt wrist
Lt wrist
Rt hand
Lt hand
Chest wall

Other

comment

Pulmonary / Nor / Abn Describe
Resp. rate
Breath sounds
Trachea
Thorax

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Complete Physical Examination eForm Patient Name: Date Page 3

Abdomen / Abs / Pre Describe
Scar(s)
Tenderness
Masses
Hernia
Hepatomegally
Splenomegally
Ascites
Nor / Abn Describe
Bowel Sounds
Anus N/E
Rectum N/E
Prostate N/E
♂Genitalia N/E
Per vaginam
Vulva N/E
Vagina N/E
Cervix N/E
BimanualN/E
Pap test / Done / Not done / Other
Comment
Cultures / Done / Not done

Musculo-skeletal Grossly normal ; or specific examination findings:

Cervical Spine (normal ROM) / N/E / Right / Left
Rotation (80°) / ° / °
Lateral Flexion (45°) / ° / °
Flexion (45°) / °
Extension (45°) / °
Shoulders (normal ROM) / N/E / Right / Left
Flexion (180°) / ° / °
Abduction: (180°) / ° / °
Ext. Rotation: (90°) / ° / °
Int Rotation(90°) / ° / °
Thoracic spine / N/E / Scoliosis: Absent Present / Kyphosis: Normal Exaggerated
Lumbar spine / N/E / Scoliosis: Absent Present / Lordosis: Normal Flattened
Shober Test / N/E / Flexion cm / Extension cm
Strght leg raise / N/E / Rt ° / Lt °
Knees N/E or: / Right / Left
Pres / Abs / Pres / Abs
Effusion
Joint Line tender
Medial
Lateral
Scars
Crepitus
Flexion (~140°)
HipsN/E or: / Rt° / Lt° / Rt° / Lt°
Flexion (125°) / Adduction (25°)
Extension (30°) / Internal Rot (40°)
Abduction (45°) / External Rot (60°)
Pos / Neg / Pos / Neg
Leg Roll Pain / Trendelenburg

Othercomment

Right / Left
N/E or: / Pos / Neg / Pos / Neg
McMurray test
Anterior Draw
Lachman
Other

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Complete Physical Examination eForm Patient Name: Date Page 4

Neurological Cranial Nerves II to XII Normal or describe below

Reflexes / N/E / Right / Left
Biceps
Triceps
Supinator
Knee
Ankle
Corneal
Abdominal
Anal
Cremasteric
Plantar
Response / Flexor
Extensor / Flexor
Extensor
Reflex grading Scale
0 / Absent even with reinforcement
++ / Hypo-reflexic
+++ / Normal
++++ / Hyper-reflexic
+++++ / Hyper-reflexic with Clonus
Motor / N/E / Nor / Abn
Muscle tone
Muscle power
Sensory
Fine touch
2 point discrim.
Pin Prick
Vibration
N/E / Nor / Abn
Finger-to-nose
Repetetitive movement
Rhomberg
Gait
Lhermitte’s ( Abs= Nor)

Lateralising signs Abs Pres -describe below

Tremor Abs Pres - describe below

Speech Nor Abn - describe below

Mental status Nor Abn - describe below

Elaborate on

neurological

findings

Integument / Abs / Pres - Describe
Rash
Nevi
Scars
Tattoos
Piercings
Nor / Abn - Describe
Nails
Other

Additional

findings:

Diagnostic Summary

Treatment Plan - No changes to current treatment or: