Printable — Clinical Form
Head-to-Toe Assessment Sheet
A systematic body-systems template with cue prompts in every section so nothing gets skipped — built for clinical rotations, skills lab, and organizing your charting before you sit down at the computer.
| T | HR | RR | BP | SpO₂ | Pain | Wt | Glucose |
|---|---|---|---|---|---|---|---|
LOC · orientation ×4 · pupils (PERRLA) · speech · strength ×4 extremities · sensation
Mucous membranes · swallow · hearing/vision aids · JVD · lymph nodes
Rate/rhythm · S1 S2 · murmurs · pulses ×4 · cap refill · edema (location/grade) · tele rhythm
Effort · breath sounds by lobe · cough · sputum · O₂ device & flow · SpO₂
Bowel sounds ×4 · abdomen (soft/firm/distended) · last BM · diet & tolerance · nausea
Voiding pattern · urine color/clarity/amount · catheter (type/day) · dialysis access
Color · temp · turgor · moisture · pressure points · wounds (site/stage/drainage) · Braden cue
ROM · gait · assistive device · activity order · fall risk (Morse cue) · restraints
Mood · affect · support system · pain (score/location/quality) · last PRN & response
IV sites (gauge/date/condition) · central lines · drains (type/output) · airway devices
Apex Nursing · apex-nursing.com — educational template; verify against facility policy. Not part of the medical record.
Educational use only. This worksheet organizes your assessment — document findings in your facility’s approved system, and dispose of patient-identifiable sheets per policy. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.