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It captures general appearance and body build, level of consciousness and orientation, eye and pupil findings, hearing and ear status, extremity strength and cranial nerve status, and pain characteristics. It also records respiratory rate and work of breathing, lung sounds, cough, oxygen support, respiratory treatments, and related observations, supporting consistent clinical evaluation and handoff communication.","| GENERAL SURVEY |  |  |  |\n| --- | --- | --- | --- |\n| How does the client look? | Age  Male/Female Body Build: | Thin Cachectic | Obese WNL |\n|  | Height  Weight  | Well groomed | Poorly Groomed |\n|  | Facial Expression: Anxious Happy Sad Angry |  |  |\n| NEUROLOGICAL |  |  |  |\n| (LOC) Level of\u003Cbr>Consciousness | Alert Awake Lethargic Obtunded Stuper Comatose Confused Decerebrate Decorticate Oriented x 4: Person Place Time Event Response to touch/voice |  |  |\n| Eyes | Unaided sight Glasses Contact lens Implants Prosthesis Snellen 20/ Blind |  |  |\n| Pupils | Equal Round Reactive to light Accommodates Sluggish Brisk Nonreactive to light Consensual Pupil size before light   mm Pupil size after light   mm |  |  |\n| Ears | Unaided hearing Hard of hearing Deaf Hearing aid Implant Cerumen Drainage |  |  |\n| Extremities | Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal |  |  |\n| Cranial Nerves-intact | I(smell) II(vision) III+IV+VI(eye movement) V(sensation of face/oral) VII (facial movement/taste) VIII (hear/balance) IX (taste/swallow) X (chew/gag/speech) XI (shrug/turn head) XII(tongue movement) |  |  |\n| Pain | Character Onset Location Duration Severity Pattern Associated Factors COLDSPA |  |  |\n|  |  |  |  |\n\n\n| Skin / Mucous Membranes | Pink Pale Cyanotic Jaundiced Ruddy Flushed Diaphoretic |  |  |\n| --- | --- | --- | --- |\n| Radial and Pedal Pulses | Radial: Palpable (L/R) Absent (L/R) Pedal: (DP PT) Palpable (L/R) Absent (L/R) |  |  |\n| Apical Radial Pulses | (2 people simultaneously) Apical and Radial Pulse Deficit |  |  |\n| Carotid Pulses | (DO NOT TAKE AT SAME TIME) Right Left Thrill Bruit |  |  |\n| Capillary Refill | Normal (\u003C3 Sec)   sec |  |  |\n| Jugular Neck Veins | Not visible Visible |  |  |\n| Edema | Absent Present: location +1 +2 +3 +4 Anasarca Pitting Non Pitting |  |  |\n| Calf Tenderness | Denies Positive Homan’s sign R L calf size R  L  (team leader or charge nurse notified) |  |  |\n| Heart Rhythm/\u003Cbr>Sounds – S1S2 | Regular Irregular Murmur Extra sounds Strong Faint Muffled Telemetry: rhythm   Pacemaker Defibrillator location |  |  |\n| IV | Solution  Rate   ml/hr Pump\u003Cbr>Site location (be specific)   Site appearance: Clear Edema Erythema Tender Pallor\u003Cbr>Dialysis access: type   Thrill Bruit Location:  Appearance:  |  |  |\n| RESPIRATORY |  |  |  |\n| Respirations | Regular Irregular Even Uneven Unlabored Labored Symmetrical Asymmetrical |  |  |\n| Lung Sounds | Clear LUL RUL LLL RLL RML Anterior Posterior\u003Cbr>Wheezes location  Rales/crackles location  Rhonchi location   Nasal flaring Sternal retraction Intercostal retraction\u003Cbr>Do lung sounds improve with cough and deep breath? If no, report to team leader |  |  |\n| Cough | None Nonproductive Dry Moist Productive Sputum:amount color frequency |  |  |\n| Oxygen | Room air Pulse ox   O2 at  L/min Nasal Cannula Mask\u003Cbr>Tent CPAP BIPAP |  |  |\n| Respiratory Treatments | Incentive Spirometer (IS): ml  frequency   hold for   seconds \\# of times \u003Cbr>HHN medication Bipap Ventilator? TV rate 02% other |  |  |\n| ALLERGIES |  | BLOOD GLUCOSE |  |\n\n\n| GASTROINTESTINAL |  |  |  |\n| --- | --- | --- | --- |\n| Oral | Teeth Dentures Caries Dysphagia Mucous Membranes: intact moist dry pale leukoplakia |  |  |\n| Abdomen: Inspect\u003Cbr>Auscultate Percuss Palpate | Soft Round Flat Scaphoid Obese Firm Hard Nondistended Distended Tender Non Tender\u003Cbr>Location: |  |  |\n| Bowel Sounds | RLQ RUQ LUQ LLQ Normoactive Hypoactive Hyperactive Absent |  |  |\n| NG/ GT/ JT | None Type of tube   patent nonpatent Suction: low high Color of drainage | amount |  |\n| Bowel Movement | Continent Incontinent last BM Color | Size Consistency | Ostomy Stool |\n| Nutrition | Diet  % eaten Breakfast  Lunch  NPO? Why \u003Cbr>Self feed Needs assistance Thickened liquids: honey nectar pudding Tube Feed  |  |  |\n\n| Urine | Continent Incontinent Catheter type   Patent Nonpatent  Color  Clear Cloudy Sediment Burning Frequency |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- ","cbCaip1Zw6pMa4zK","https://ap.wps.com/l/cbCaip1Zw6pMa4zK","pdf",654763,2,"English","en",105,"# General Survey\n## Neurological\n## Respiratory\n## Allergies and Blood Glucose\n## Gastrointestinal\n## Urine and Intake/Output\n## Genitalia and Musculoskeletal\n## Integumentary\n## Psychosocial","[{\"question\":\"What sections are included in the head-to-toe assessment?\",\"answer\":\"The form organizes findings by systems, including General Survey, Neurological, Respiratory, Gastrointestinal, Urine and Intake/Output, Musculoskeletal, Integumentary, and a Psychosocial section.\"},{\"question\":\"How is neurological status documented?\",\"answer\":\"Neurological status includes level of consciousness and orientation (e.g., person/place/time/event and response to touch/voice), eye findings, pupil characteristics, ear findings, extremity strength/grip and foot pushes, cranial nerve integrity, and pain details.\"},{\"question\":\"What respiratory data does the form request?\",\"answer\":\"It captures respirations (regular/irregular, labored/unlabored, symmetry), lung sounds by location, wheezes/rales/rhonchi distribution, cough characteristics, oxygen modality and settings, and respiratory treatments such as incentive spirometry and nebulized medications.\"}]","Head to Toe Patient Assessment - General Survey - Neurological - Respiratory | PDF",1788439224,{"code":4,"msg":75,"data":76},"ok",{"site_id":69,"language":68,"slug":77,"title":59,"keywords":78,"description":60,"schema_data":79,"social_meta":134,"head_meta":136,"extra_data":138,"updated_unix":139},"head-to-toe-patient-assessment-general-survey-neurological-respiratory","",{"@graph":80,"@context":133},[81,96,116],{"@type":82,"itemListElement":83},"BreadcrumbList",[84,88,90,93],{"item":85,"name":86,"@type":87,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":89,"name":10,"@type":87,"position":66},"https://docshare.wps.com/template/",{"item":91,"name":36,"@type":87,"position":92},"https://docshare.wps.com/template/forms/",3,{"item":94,"name":59,"@type":87,"position":95},"https://docshare.wps.com/template/head-to-toe-patient-assessment-general-survey-neurological-respiratory/194450/",4,{"url":94,"name":59,"@type":97,"image":98,"author":103,"headline":59,"publisher":105,"fileFormat":108,"inLanguage":68,"description":60,"dateModified":109,"datePublished":110,"encodingFormat":108,"isAccessibleForFree":111,"interactionStatistic":112},"DigitalDocument",{"url":99,"@type":100,"width":101,"height":102},"https://docshare.wps.com/thumbnails/head-to-toe-patient-assessment-general-survey-neurological-respiratory/194450.png","ImageObject",442,249,{"name":57,"@type":104},"Person",{"url":85,"name":106,"@type":107},"DocShare","Organization","application/pdf","2026-10-03","2026-09-03",true,{"@type":113,"interactionType":114,"userInteractionCount":92},"InteractionCounter",{"@type":115},"ViewAction",{"@type":117,"mainEntity":118},"FAQPage",[119,125,129],{"name":120,"@type":121,"acceptedAnswer":122},"What sections are included in the head-to-toe assessment?","Question",{"text":123,"@type":124},"The form organizes findings by systems, including General Survey, Neurological, Respiratory, Gastrointestinal, Urine and Intake/Output, Musculoskeletal, Integumentary, and a Psychosocial section.","Answer",{"name":126,"@type":121,"acceptedAnswer":127},"How is neurological status documented?",{"text":128,"@type":124},"Neurological status includes level of consciousness and orientation (e.g., person/place/time/event and response to touch/voice), eye findings, pupil characteristics, ear findings, extremity strength/grip and foot pushes, cranial nerve integrity, and pain details.",{"name":130,"@type":121,"acceptedAnswer":131},"What respiratory data does the form request?",{"text":132,"@type":124},"It captures respirations (regular/irregular, labored/unlabored, symmetry), lung sounds by location, wheezes/rales/rhonchi distribution, cough characteristics, oxygen modality and settings, and respiratory treatments such as incentive spirometry and nebulized medications.","https://schema.org",{"og:url":94,"og:type":135,"og:title":59,"og:site_name":106,"og:description":60},"article",{"robots":137,"canonical":94},"index,follow",{"doc_id":55,"site_id":69},1790129607]