Davao Doctors
College, Inc.
Gen. Malvar
St., Davao City
College of Allied Health Sciences | Nursing Program
COMPREHENSIVE HEALTH ASSESSMENT
Name of Patient: __________________________________________ Age: _____ Sex: _____ Civil Status:
_________ Impression/ Diagnosis:
____________________________________________________________________________ Date of Admission:
____________________ Attending Physician: _____________________ Room No.: ___________ Date of
Assessment: ________________
I.HEALTH HISTORY
Chief Complaint: __________________________________________________________________________________
Present health status:
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
Past health history:
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
Current Lifestyle:
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
Psychosocial status:
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
Family history:
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
Gynecologic history (if applicable):
Menstrual History (Usual Cycle) Interval: ________ Duration: ________ Amount of Menstrual Flow: _________ Last
Menstrual Period and LMP: ______________ EDD: ____________________ Expected Date of Delivery
History of Dysmenorrhea? [ ] Yes [ ] No Gynecologic surgeries? [ ] No [ ] Yes; pls. specify:________
Obstetric history (if applicable):
Pregnancy Profile (GPTAL) Gravity: ___ Term: ___ Preterm: ___ Abortions: ___ Living Children: ____
/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE
Comprehensive Health Assessment Form | Page 1 of 8
Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program
Previous Pregnancies? [ ] No [ ] Yes; Please specify in chronological order):
Date: Name of Child Type of Delivery Outcome
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
_______________________________________________________________________________________
_
II. PHYSICAL EXAMINATION
A. PRELIMINARIES
VITAL SIGNS AND ANTHROPOMETRIC MEASUREMENTS
Blood pressure: _____________________________ Height: _____________________________ Heart
rate: _____________________________ Weight: ____________________________ Pulse Rate:
_____________________________ BMI: _______________________________
Temperature: _____________________________ [ ] within ideal body weight (IBW)
Respiratory Rate: _____________________________ [ ] less than IBW
Others: _____________________________ [ ] more than IBW; specify:
GENERAL SURVEY:
B. INTEGUMENT
SKIN
Color: ________________________________________________________________________________________
Texture:
________________________________________________________________________________________ Turgor:
________________________________________________________________________________________ Scaling:
________________________________________________________________________________________ Hair
Distribution: __________________________________________________________________________________
Hair Characteristics:
_______________________________________________________________________________ Infestation:
______________________________________________________________________________________
Comments:
______________________________________________________________________________________
STOMA[ ] not Applicable
[ ] clean dry [ ] redness [ ] chronic redness [ ] drainage [ ] chronic drainage [ ] prolapsed
/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE
Comprehensive Health Assessment Form | Page 2 of 8
Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program
Comments: ______________________________________________________________________________________
FINGERNAILS & TOENAILS
[ ] color, chare, cleanliness good [ ] no problems or deviations assessed
[ ] irregularities in surface:
__________________________________________________________________________ [ ] inflammation around
nails: ________________________________________________________________________ [ ] fungal problem:
_________________________________________________________________________________ C. HEAD AND
NECK
HEAD & NECK
Head motion (describe): ___________________________________________________________________________
[ ] asymmetric head position (describe): _______________________________________________________________
[ ] shrugs shoulders [ ] unable to support head midline & erect [ ] dull, puffy, yellow skin [ ] peritoneal edema [ ] lymph
node enlargement [ ] thyroid enlargement [ ] tracheal displacement Comments:
______________________________________________________________________________________
NOSE & SINUSES
[ ] nasal drainage [ ] inflamed [ ] tender [ ] polyps/lesions [ ] edema [ ] altered nasal mucosa (describe):
___________________________________________________________________ [ ] absence of frontal sinus glow [ ]
right nostril occluded [ ] left nostril occluded
Comments: ______________________________________________________________________________________
MOUTH & PHARYNX
[ ] altered oral mucous membrane (describe):
___________________________________________________________ [ ] Inflammation (describe):
__________________________________________________________________________ [ ] hoarseness [ ] bruxism
(grinds teeth) [ ] loose teeth [ ]decay [ ]halitosis [ ] excessive salivation [ ] lips dry, cracked [ ] lip fissures [ ] lip bleeding [
] gums inflamed [ ] gums bleed [ ]gum retraction [ ] thick tongue [ ] tongue dry, cracked [ ] tongue fissures[ ] tongue
bleeds
Inspected the following:
[ ] Inner oral mucosa [ ] buccal mucosa [ ] floor of mouth and tongue [ ]hard palate [ ] soft palate Deviations (describe):
______________________________________________________________________________ [ ] lesions, vesicles
(describe): _______________________________________________________________________ [ ] gag reflex
absent [ ] gag reflex hyperactive [ ]poor denture fit or not using [ ] chewing problem [ ] missing teeth Comments:
______________________________________________________________________________________
D. EYES AND EARS
EYES
Visual acuity:
____________________________________________________________________________________ Visual
fields/peripheral: ____________________________________________________________________________ Eye
tracking present: [ ] up [ ] down [ ]right [ ] left [ ] corneal light reflex aligned [ ] light reflex misaligned [ ]nystagmus
External eye structure:
Abnormalities (specify/describe):
_____________________________________________________________________ Blink reflex:
______________________________________________________________________________________ Pupil & Iris
direct light response: _____________________________________________________________________ Pupil &
Iris consensual light response: _________________________________________________________________
Ophthalmoscopic exam:
____________________________________________________________________________ Unable to do
ophthalmoscope exam due to: ____________________________________________________________ Comments:
______________________________________________________________________________________
/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE
Comprehensive Health Assessment Form | Page 3 of 8
Davao Doctors College, Inc.
Gen. Malvar St., Davao City
College of Allied Health Sciences | Nursing Program
EARS
External ear structures:
____________________________________________________________________________ External ear structure
abnormalities: __________________________________________________________________ Other abnormalities
(describe): ______________________________________________________________________ Otoscopic exam:
[ ] cone of light visualized [ ] cone of light not visualized [ ] tympanic membrane inspected [ ] excessive cerumen [ ]
Unable to examine [ ]Simple hearing acuity test:
Comments: _____________________________________________________________________________________
E. CARDIOPULMONARY
HEART & VASCULAR
Auscultated heart sounds:
_________________________________________________________________________ Apical pulse (rate &
rhythm): _______________________________________________________________________ Jugular venous
distention: [ ] present [ ] absent Capillary refill: [ ] > 1 second [ ] < 2 seconds [ ] PMI palpable – 5th intercostal space
medial to left midclavicular line [ ] PMI not palpable [ ] edema (describe):
_____________________________________________________________________________ Blood Pressure:
________________________________ MAP: _________________ [ ] Pulse Deficit: _____________ Peripheral
Pulses: _______________________________________________________________________________
Comments:
_____________________________________________________________________________________
THORAX & LUNGS
Inspected: [ ] posterior thorax [ ] lateral thorax [ ] anterior thorax
Thorax deviations: [ ] scoliosis [ ] lordosis [ ]barrel chest [ ] intercostal bulging [ ] Others:
____________________________________________________________________________________
Auscultated breath sounds:
[ ] vesicular sounds at periphery
[ ] bronchovesicular sounds between scapulae or 1st – 2nd intercoastal space lateral to sternum
[ ] bronchial sounds over trachea
Adventitious sounds: [ ] wheezes [ ] crackles [ ] rhonchi Location: ________________________________________ [ ]
clear with cough [ ] Other: _______________________________________________________________________
Respiratory distress: [ ] nasal flaring [ ] use of accessory muscles, specify: __________ [ ] SOB [ ] Intercoastal retraction
Respiratory Rate: _____________Oxygen Saturation: ______________ [ ] apnea, _____________________________
Comments: _____________________________________________________________________________________
F. GASTROINTESTINAL
ABDOMEN
Bowel Sounds: [ ] Present in all quadrants, counts per minute: __________________ [ ] absent: [ ]
hypoactive [ ] hyperactive [ ] tympanic
Abdomen: [ ] flat [ ] distended [ ] soft [ ] firm [ ] rounded [ ] obese [ ] asymmetry [ ] pain [ ] rebound tenderness [ ]
umbilical hernia:
[]
Others:_________________________________________________________________________ [
] gastrostomy [ ] jejunostomy [ ] large intestine transverse ostomy
[ ] large intestine sigmoid ostomy
[ ] mass:
__________________________________________________________________________ Abdominal Skin
Characteristics:______________________________________________________________________ Comments:
______________________________________________________________________________________
G. GENITOURINARY (GYNECOLOGICAL & BREASTS)
/DDCNSGFORMS/2020/HA/ECAJES.BNIEVE Comprehensive Health Assessment Form | Page 4 of 8
Davao Doctors
College, Inc.
Gen. Malvar
St., Davao City
College of Allied Health
Sciences | Nursing Program
