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Physical Exam
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GENERAL
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GENERAL Examined?
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GENERAL assessment findings
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General WNL?
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General unlisted positive findings
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SKIN
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SKIN Examined?
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SKIN LESION(S)?
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Skin WNL?
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SKIN assessment findings
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LOCATION of SKIN RASH
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DESCRIPTION of SKIN LESION
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Skin Comments
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Size of Lesion (in millimeters)
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Type
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Location of Lesion
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Distribution
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Arrangement
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Color
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Photo #1
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PHOTO 1
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Photo #2
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PHOTO 2
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Photo #3
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PHOTO 3
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Photo #4
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PHOTO 4
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Photo #5
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PHOTO 5
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Photo #6
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PHOTO 6
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Photo #7
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PHOTO 7
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HEENT
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HEENT Examined?
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HEENT assessment findings
• • •
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HEENT WNL?
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HEENT additional unlisted positive findings
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EYES assessment findings
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EARS assessment findings:
• • •
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NOSE assessment findings
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OROPHARYNX assessment findings
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NECK
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NECK Examined?
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NECK assessment findings
• • •
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Neck WNL?
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Neck additional positive findings
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CARDIOVASCULAR
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CARDIOVASCULAR Examined?
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CV assessment findings
• • •
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Cardiovascular WNL?
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Cardiovascular Comments
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PULMONARY
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PULMONARY Examined?
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PULMONARY assessment findings
• • •
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Lungs WNL?
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Lungs Comments
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ABDOMEN
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ABDOMEN Examined?
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ABDOMEN assessment findings
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Abdomen WNL?
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Abdomen Comments
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MUSCULOSKELETAL (MSK)
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MSK Examined?
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MSK assessment findings
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MSK WNL?
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MSK Comments
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BREASTS
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BREASTS Examined?
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BREAST assessment findings
• • •
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Breasts WNL?
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Breasts Comments
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NEURO
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NEURO Examined?
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NEURO assessment findings
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Neuro WNL?
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Sensory Deficit?
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Motor Weakness
• • •
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DTR
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Neuro Comments
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EXTREMITIES
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EXTREMITIES Examined?
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EXTREMITIES assessment findings
• • •
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Extremities WNL?
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Extremity Comments
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Extremity Lesion Location
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GENITAL (MALE)
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GENITAL (MALE) Examined?
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Genital (MALE) assessment findings
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Genital (MALE) WNL?
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Genital (MALE) Comments
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GENITAL (FEMALE)
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GENITAL (FEMALE) Examined?
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GENITAL (FEMALE) assessment findings
• • •
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Genital (FEMALE) WNL?
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Genital (FEMALE) Comments
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Speculum Exam
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Female GU Speculum Exam
• • •
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