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Head to Toe Assessment Form Template

A comprehensive tool for thorough patient evaluations

Getting a complete picture of your patient's health can feel daunting, but with the right tools, it doesn't have to be. This Head to Toe Assessment Form Template is designed for healthcare professionals seeking to perform systematic evaluations efficiently. You'll benefit from organized, detailed documentation, improved patient communication, and accurate assessments, all while ensuring compliance with WCAG standards. Experience streamlined workflows and better patient outcomes as you use this live template to enhance your assessment process.

Use this Template (FREE) Live Preview
Full name
Date of birth
Phone number
Email address
Assessment date
Medical record number or patient ID
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
I consent to a head-to-toe assessment being performed today
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Patient or guardian printed name (as signature)
Signature date
I authorize sharing assessment findings with my primary care provider
Yes
No
Do you have any allergies?
Yes
No
Allergy details (substances and reactions)
Current medications (name, dose, frequency)
Pain details (location, characteristics, duration, triggers, relief)
Are you currently experiencing any pain?
Yes
No
Blood pressure (mmHg)
Heart rate (bpm)
Respiratory rate (breaths/min)
Temperature (include unit)
Oxygen saturation (%)
General appearance
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Skin (color, temperature, turgor, lesions)
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Head and scalp
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Eyes (pupils, vision, conjunctiva)
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Ears, nose, mouth, and throat
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Neck and lymph nodes
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Respiratory system (inspection, auscultation, effort)
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Cardiovascular system (heart sounds, rhythm, perfusion)
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Abdomen/Gastrointestinal
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Genitourinary
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Musculoskeletal (ROM, strength, tenderness)
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Exam notes and key findings
Neurological (LOC, orientation, cranial nerves, sensation)
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Gait and balance
Normal
Mild abnormality
Moderate abnormality
Severe abnormality
Not assessed
Not applicable
Assistive devices used
None
Cane
Walker
Wheelchair
Crutches
Prosthesis
Orthosis/brace
Other
Please Specify:
Any falls in the past 6 months?
Yes
No
Overall condition today
Poor
Fair
Good
Very good
Excellent
Recommendations and plan
Next review date
Is follow-up needed?
Yes
No
Clinician name
Assessment completion date
Role/title
RN
LPN/LVN
NP
PA
MD/DO
PT
OT
Other
Please Specify:
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Date of birth, Phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a head to toe assessment form template for medical evaluations and documentation.

When to use this form

This form is ideal for clinics, hospital units, and home health when you need a fast, structured body systems check. Use it for new patient intake, shift-to-shift comparisons, post-fall reviews, and post-op monitoring. It helps nurses and medical assistants capture vitals, neuro, respiratory, cardiac, GI/GU, skin, and mobility findings in one place. If symptoms suggest focal deficits, pair it with the Neurological exam form to go deeper. For complex cases or annual physicals, link the summary to the Medical assessment form to build a fuller record and care plan.

Must Ask Head to Toe Assessment Questions

  1. What are the current vital signs (BP, HR, RR, temperature, SpO2)?

    These numbers reveal immediate risk and guide triage. Tracking exact values and trends helps you spot deterioration early and act.

  2. Are you in pain now? Where is it, how intense (0-10), and what does it feel like?

    Pain location and quality point to likely causes and urgency. Clear descriptors allow targeted treatment and show response over time.

  3. Are you alert and oriented to person, place, time, and situation?

    Orientation changes can signal hypoxia, stroke, infection, or medication effects. Quick checks here prompt further neuro assessment and safety measures.

  4. Describe your breathing: rate, effort, cough or sputum, and oxygen use.

    Respiratory status affects most decisions, from positioning to escalation. Documenting effort and supports clarifies severity and needed interventions.

  5. Do you have new skin changes, wounds, swelling, or mobility limits?

    Skin and mobility findings reveal perfusion, pressure risk, and fall risk. You can pair this with the Self-health assessment form to capture patient-reported changes between visits.

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