Sample physical exam form template

Routine Physical Examinations are assessments typically performed on asymptomatic patients. Asymptomatic means that the patient does not harbor any symptoms of illness or disease. Routine Exams are usually done for screening purposes and are normally conducted by pediatrician, physician, primary care providers, and a certified nurse. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is normal upon percussion of all lung fields.

Abdominal: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted. No external masses or lesions. Stool is normal in appearance. External genitalia is normal in appearance without lesions, swelling, masses or tenderness. Vagina is pink and moist without lesions or discharge.

Cervix is non-tender without lesions or erosions. Uterus is anteflexed, non-tender and normal in size. Ovaries are non-tender without palpable masses or enlargement. Spine: Neck and back are without deformity, external skin changes, or signs of trauma.

Curvature of the cervical, thoracic, and lumbar spine are within normal limits. Bony features of the shoulders and hips are of equal height bilaterally. Posture is upright, gait is smooth, steady, and within normal limits. No tenderness noted on palpation of the spinous processes. Spinous processes are midline.

Cervical, thoracic, and lumbar paraspinal muscles are not tender and are without spasm. No discomfort is noted with flexion, extension, and side-to-side rotation of the cervical spine, full range of motion is noted. Full range of motion including flexion, extension, and side-to-side rotation of the thoracic and lumbar spine are noted and without discomfort. Straight leg raise test is negative bilaterally.

Sensation to the upper and lower extremities is normal bilaterally. No clonus is noted. Grip strength is normal bilaterally. Extremities: Upper and lower extremities are atraumatic in appearance without tenderness or deformity. No swelling or erythema. Full range of motion is noted to all joints. Tendon function is normal. Capillary refill is less than 3 seconds in all extremities.

Pulses palpable. Steady gait noted. Physical Exams are a way of conducting preventive medicine for anyone regardless of race, age, sex, or level of activity. Physical Examinations are commonly dubbed check-ups and are a process in which a doctor or a clinician examines or assesses the body of the patient for any sign of disease. Disease Screening. Physical Examinations helps in disease screening. Gait is normal. Deep tendon reflexes are intact. Recent and remote memory is intact.

Appropriate mood and affect. SKIN: Warm, dry, and well perfused. Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. PE Sample 1. Eyes: Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and nonicteric. Nose: Nasal mucosa is pink and moist. Septum is midline. Mouth: Oral mucosa is pink and moist. Dentition is good. There is no jugular venous distention noted.

There are no carotid bruits noted. There are no palpable masses. There are no crackles, wheezes or rhonchi noted. There is no crepitus on palpation. No murmurs are noted. There are no lifts, heaves or thrills noted on palpation. There are good bowel sounds. There is no rebound or guarding. There is no evidence of hernia. SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor.