Head-to-Toe Assessment Script
My name is Stacey and I'm a student nurse. I'm going to be conducting your head-to-toe
examination. Do you have any questions for me today? Correct answer- Okay, let's get
started then. Can you state your full name for me? And what is your data of birth? (Go
wash hands)
I'm going to take your vital signs now. Let me first estimate your blood pressure and
we'll come back to that. Your pulse is ______ and your respirations are
_______/minute. Your temperature is ___________. Now I'm going to take blood
pressure. Your blood pressure is ________________ Correct answer- I'm going to be
observing the patient's skin throughout the exam. May I remove your glasses? Your
facial features look symmetrical. (Put on gloves)The scalp does not have any lesions or
pest inhabitants. Remove gloves and gel hands.
I'm going to feeling for any lumps or tenderness in your face. Does this hurt? Now I'm
going to check your sinuses. Does this hurt?(press up under eyebrows) How about this
(press up under zygomatic). Let's check your to see that your jaw is working smoothly
(press at TMJ). Good, I don't feel any clicking or crepitus and your jaw opens smoothly.
Correct answer- Now I'm going to test facial sensation with this cotton ball. I'm going to
have you shut your eyes and tell me "now" when you feel the cotton on your skin like
this (brush cotton on pts arm). Can you shut your eyes please? (brush cotton on
forehead, cheek and mandible). Good, you can open your eyes now. (palpate
temporalis) Can you clench your jaw? Good. (palpate masseter) Clench again. Good.
Your facial sensations are intact and your have good jaw strength so I know that your
5th cranial nerve is intact.
Now we're going to test your facial nerve. Can you make a frown? a smile? show your
teeth? and now puff out the cheeks. Good. The nerve is intact. Correct answer- I'm
going to take a look your eyes now. (look for any redness or assymetry in eyes). Can
you shut your eyes for a moment. Good, the eyes, lids and lashes are all healthy.
Now I'm going to test eye muscles. Can you follow my finger as I pass through the six
positions? (Hold at extreme left and right) Ok, and now just look at a point behind my
head as I shine this light. Good, your eye muscles are healthy and I did not see any sign
of lazy eye. The cranial nerves 3, 4 and 6 controlling eye moments are all intact. Correct
answer- Let's take a look at the cornea(light side to front). Good. Looks smooth and
round with no scratches. (Pull down bottom lid) the lining of the eyelid is pink and
healthy. Iris and pupil are round and symmetrical.
I'm going to check your pupil reaction now. Can I have you hold your hand up like this?
(direct and consensual test) Good. The pupillary responses are intact. Now let me have
you focus your gaze on a point on the wall behind me. Now look at my finger. Good.
My name is Stacey and I'm a student nurse. I'm going to be conducting your head-to-toe
examination. Do you have any questions for me today? Correct answer- Okay, let's get
started then. Can you state your full name for me? And what is your data of birth? (Go
wash hands)
I'm going to take your vital signs now. Let me first estimate your blood pressure and
we'll come back to that. Your pulse is ______ and your respirations are
_______/minute. Your temperature is ___________. Now I'm going to take blood
pressure. Your blood pressure is ________________ Correct answer- I'm going to be
observing the patient's skin throughout the exam. May I remove your glasses? Your
facial features look symmetrical. (Put on gloves)The scalp does not have any lesions or
pest inhabitants. Remove gloves and gel hands.
I'm going to feeling for any lumps or tenderness in your face. Does this hurt? Now I'm
going to check your sinuses. Does this hurt?(press up under eyebrows) How about this
(press up under zygomatic). Let's check your to see that your jaw is working smoothly
(press at TMJ). Good, I don't feel any clicking or crepitus and your jaw opens smoothly.
Correct answer- Now I'm going to test facial sensation with this cotton ball. I'm going to
have you shut your eyes and tell me "now" when you feel the cotton on your skin like
this (brush cotton on pts arm). Can you shut your eyes please? (brush cotton on
forehead, cheek and mandible). Good, you can open your eyes now. (palpate
temporalis) Can you clench your jaw? Good. (palpate masseter) Clench again. Good.
Your facial sensations are intact and your have good jaw strength so I know that your
5th cranial nerve is intact.
Now we're going to test your facial nerve. Can you make a frown? a smile? show your
teeth? and now puff out the cheeks. Good. The nerve is intact. Correct answer- I'm
going to take a look your eyes now. (look for any redness or assymetry in eyes). Can
you shut your eyes for a moment. Good, the eyes, lids and lashes are all healthy.
Now I'm going to test eye muscles. Can you follow my finger as I pass through the six
positions? (Hold at extreme left and right) Ok, and now just look at a point behind my
head as I shine this light. Good, your eye muscles are healthy and I did not see any sign
of lazy eye. The cranial nerves 3, 4 and 6 controlling eye moments are all intact. Correct
answer- Let's take a look at the cornea(light side to front). Good. Looks smooth and
round with no scratches. (Pull down bottom lid) the lining of the eyelid is pink and
healthy. Iris and pupil are round and symmetrical.
I'm going to check your pupil reaction now. Can I have you hold your hand up like this?
(direct and consensual test) Good. The pupillary responses are intact. Now let me have
you focus your gaze on a point on the wall behind me. Now look at my finger. Good.
