Health Assessment Script
Western Governors University
, lOMoARcPSD|51648332
stethoscope, a penlight or flashlight, watch or timer, BP cuff (manual or automatic),
reflex hammer, and cotton swab/pen cap.
Intro
- Introduce self then patient
- What are you here for
o A physical examination
- Can I have your permission to exam you and touch you?
- Patient identification
o Full name
o DOB
- A/O’s
o Name
o Year
o What city/state
o Patient is A/O x3
- Do you have any pertinent medical history?
- Visual Inspection
- Assess nutritional status
o Nutritional st is appropriate for age
- Posture
o Patients posture is appropriate for age
- No apparent physical deformities present
C1. Part 1: Measurements, Skin, & Head/Face
Vital Signs
1. Ask height and weight
2. Measure radial pulse (bpm) x 30 sec -74
3. Measure respiratory rate- 18 regular and unlabored
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, lOMoARcPSD|51648332
4. Measure blood pressure (arm)
5. Assess current pain level- No pain
Skin (bilateral)
6. Assess skin color/pigmentation- Appropriate for age and race
7. Assess skin temperature- warm
8. Assess skin moisture- Dry
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