Physical Exam Checklist Template

How Do I Create a Physical Exam Checklist Template? Complete Clinical Assessment Guide

Physical exam checklist templates provide systematic frameworks for healthcare professionals to conduct comprehensive patient assessments, ensuring thorough evaluation of all body systems while maintaining consistency and reducing the risk of overlooking critical clinical findings. These structured checklists support quality patient care, facilitate clinical education, and enhance documentation accuracy across various healthcare settings.

What Essential Components Must Every Physical Exam Checklist Include?

Comprehensive physical examination requires systematic evaluation of multiple body systems with standardized assessment techniques and documentation methods.

Patient Preparation and Setup

Ensure appropriate environment, equipment availability, patient positioning, and privacy measures. Document patient consent, comfort level, and any limitations that may affect the examination process.

Vital Signs and General Assessment

Measure and record temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, height, weight, and BMI. Include pain assessment and general appearance observations.

System-Specific Examinations

Conduct thorough evaluation of each body system including inspection, palpation, percussion, and auscultation techniques as appropriate. Document both normal and abnormal findings with specific descriptions.

Functional Assessment and Special Tests

Include relevant functional assessments, neurological testing, and specialty-specific maneuvers based on patient presentation and clinical indications.

How Do I Design a Comprehensive Physical Exam Checklist Template?

COMPLETE PHYSICAL EXAM CHECKLIST TEMPLATE

PRE-EXAMINATION PREPARATION:

Date: _________ Time: _______ Provider: ______________
Patient Name: ___________________________________
Age: _____ Gender: ______ MRN: __________________

Examination Environment:
☐ Private room ☐ Adequate lighting ☐ Comfortable temperature
☐ All equipment available ☐ Hand hygiene completed
☐ Patient identification verified

Patient Preparation:
☐ Consent obtained ☐ Gown provided ☐ Chaperone offered
☐ Patient positioned appropriately ☐ Comfort assessed
☐ Examination explained ☐ Questions answered

VITAL SIGNS ASSESSMENT:

Temperature: ____°F/°C ☐ Oral ☐ Tympanic ☐ Temporal ☐ Axillary
Blood Pressure: / mmHg ☐ Right arm ☐ Left arm
☐ Sitting ☐ Standing ☐ Supine
Heart Rate: _____ bpm ☐ Regular ☐ Irregular
Respiratory Rate: _____ breaths/minute
Oxygen Saturation: _____% ☐ Room air ☐ O2 ____L/min
Height: ______ Weight: ______ BMI: _____________
Pain Score: _____/10 Location: ___________________

GENERAL APPEARANCE:

☐ Well-appearing ☐ Ill-appearing ☐ NAD ☐ Acute distress
☐ Alert ☐ Oriented ☐ Cooperative ☐ Pleasant
☐ Anxious ☐ Depressed ☐ Agitated ☐ Lethargic

Hygiene and Grooming:
☐ Well-groomed ☐ Poor hygiene ☐ Appropriate dress
☐ Body odor noted ☐ Other: ____________________

Speech and Communication:
☐ Clear speech ☐ Appropriate volume ☐ Normal pace
☐ Language barrier ☐ Hearing difficulty
☐ Other: ____________________________________

HEAD AND NECK EXAMINATION:

Head:

Inspection:
☐ Normocephalic ☐ Atraumatic ☐ No deformities
☐ Scalp lesions ☐ Hair distribution normal
☐ Other findings: ____________________________

Palpation:
☐ No tenderness ☐ No masses ☐ Fontanelles closed (pediatric)
☐ Abnormal findings: __________________________

Eyes:

Visual Acuity: Right: _____ Left: _____
☐ Glasses/contacts ☐ No correction needed

External Examination:
☐ Symmetric ☐ No ptosis ☐ No swelling
☐ Lids/lashes normal ☐ No discharge
☐ Abnormal findings: __________________________

Pupils:
☐ PERRL ☐ Equal size ☐ Reactive to light
Right: ___mm Left: ___mm
☐ Direct reflex ☐ Consensual reflex

Extraocular Movements:
☐ EOMI ☐ No nystagmus ☐ Full ROM
☐ Abnormal findings: __________________________

Conjunctiva and Sclera:
☐ Pink ☐ Moist ☐ No injection ☐ No icterus
☐ Abnormal findings: __________________________

Ophthalmoscopy (if indicated):
☐ Red reflex present ☐ Optic discs normal
☐ Vessels normal ☐ Retina normal
☐ Abnormal findings: __________________________

Ears:

External Ear:
☐ No deformities ☐ No tenderness ☐ No discharge
☐ Hearing aid present ☐ Piercing noted
☐ Abnormal findings: __________________________

Otoscopy:
Right ear: ☐ TM clear ☐ Light reflex present ☐ Mobile
☐ Cerumen ☐ Drainage ☐ Perforation
Left ear: ☐ TM clear ☐ Light reflex present ☐ Mobile
☐ Cerumen ☐ Drainage ☐ Perforation

Hearing Assessment:
☐ Whisper test normal ☐ Weber test ☐ Rinne test
☐ Hearing impairment noted
☐ Results: __________________________________

Nose and Sinuses:

External Nose:
☐ No deformity ☐ No tenderness ☐ No discharge
☐ Abnormal findings: __________________________

Nasal Cavity:
☐ Patent ☐ Septum midline ☐ Mucosa pink/moist
☐ No polyps ☐ No discharge ☐ No bleeding
☐ Abnormal findings: __________________________

Sinuses:
☐ Frontal - no tenderness ☐ Maxillary - no tenderness
☐ Transillumination normal (if performed)
☐ Abnormal findings: __________________________

Mouth and Throat:

Lips: ☐ Pink ☐ Moist ☐ No lesions ☐ No cyanosis
Teeth: ☐ Good dentition ☐ Dental work noted ☐ Missing teeth
Gums: ☐ Pink ☐ No bleeding ☐ No swelling
Tongue: ☐ Pink ☐ Midline ☐ Normal size ☐ No lesions
☐ Papillae normal ☐ Movement normal

Palate: ☐ Intact ☐ Pink ☐ No lesions
Tonsils: ☐ Normal size ☐ No erythema ☐ No exudate
☐ Surgically absent
Pharynx: ☐ Clear ☐ No erythema ☐ No exudate
☐ Posterior pharynx clear

Abnormal findings: ______________________________

Neck:

Inspection:
☐ No masses ☐ Symmetric ☐ No lymphadenopathy
☐ No visible thyroid enlargement ☐ No JVD
☐ Abnormal findings: __________________________

Palpation:
☐ Supple ☐ No tenderness ☐ No masses
☐ Lymph nodes: ☐ Not palpable ☐ Small, mobile, non-tender
☐ Thyroid: ☐ Not palpable ☐ Normal size ☐ No nodules

Range of Motion:
☐ Full flexion ☐ Full extension ☐ Full rotation
☐ Full lateral flexion ☐ No stiffness ☐ No pain
☐ Limitations noted: __________________________

CARDIOVASCULAR EXAMINATION:

Inspection:
☐ No visible pulsations ☐ No heaves ☐ No deformities
☐ Chest symmetric ☐ No cyanosis ☐ No edema
☐ Abnormal findings: __________________________

Palpation:
☐ PMI at 5th ICS MCL ☐ No heaves ☐ No thrills
☐ Abnormal findings: __________________________

Auscultation:
Rate: _____ bpm ☐ Regular ☐ Irregularly irregular
☐ Regularly irregular

Heart Sounds:
☐ S1 normal ☐ S2 normal ☐ S3 absent ☐ S4 absent
☐ No murmurs ☐ No rubs ☐ No gallops

If murmur present:
Location: ___________________________________
Timing: ☐ Systolic ☐ Diastolic ☐ Continuous
Grade: _____/6 Quality: ______________________
Radiation: _________________________________

Peripheral Pulses:
Radial: ☐ 2+ ☐ 1+ ☐ Absent Right: ___ Left: ___
Dorsalis pedis: ☐ 2+ ☐ 1+ ☐ Absent Right: ___ Left: ___
Posterior tibial: ☐ 2+ ☐ 1+ ☐ Absent Right: ___ Left: ___

RESPIRATORY EXAMINATION:

Inspection:
☐ No respiratory distress ☐ Symmetric chest expansion
☐ No use of accessory muscles ☐ No cyanosis
☐ No barrel chest ☐ No pectus deformity
☐ Abnormal findings: __________________________

Palpation:
☐ No tenderness ☐ Symmetric tactile fremitus
☐ Normal chest expansion ☐ No subcutaneous emphysema
☐ Abnormal findings: __________________________

Percussion:
☐ Resonant throughout ☐ No dullness ☐ No hyperresonance
☐ Abnormal findings: __________________________

Auscultation:
☐ Clear to auscultation bilaterally
☐ No wheezes ☐ No rhonchi ☐ No rales ☐ No stridor
☐ Vesicular breath sounds throughout
☐ Abnormal findings: __________________________

Location of abnormal sounds: ____________________

ABDOMINAL EXAMINATION:

Inspection:
☐ Flat ☐ Soft ☐ Non-distended ☐ No masses visible
☐ No surgical scars ☐ Umbilicus normal
☐ No hernias ☐ No visible peristalsis
☐ Abnormal findings: __________________________

Auscultation (before palpation):
☐ Bowel sounds present ☐ Normal frequency
☐ No bruits ☐ No venous hums
☐ Abnormal findings: __________________________

Percussion:
☐ Tympanic ☐ No organomegaly ☐ Normal liver span
☐ No fluid wave ☐ No shifting dullness
☐ Abnormal findings: __________________________

Palpation:
Light Palpation:
☐ Soft ☐ Non-tender ☐ No masses ☐ No rigidity
☐ No guarding ☐ No rebound tenderness

Deep Palpation:
☐ No masses ☐ No organomegaly ☐ No tenderness
☐ Liver: ☐ Not palpable ☐ Normal size
☐ Spleen: ☐ Not palpable ☐ Normal size
☐ Kidneys: ☐ Not palpable

Special Tests (if indicated):
☐ Murphy's sign negative ☐ McBurney's point non-tender
☐ CVA tenderness absent ☐ Psoas sign negative
☐ Obturator sign negative

Abnormal findings: ______________________________

MUSCULOSKELETAL EXAMINATION:

General:
☐ Normal posture ☐ Symmetric ☐ Normal gait
☐ No obvious deformities ☐ No swelling
☐ No muscle atrophy ☐ No fasciculations

Upper Extremities:
☐ Full ROM all joints ☐ 5/5 strength throughout
☐ No swelling ☐ No deformities ☐ No tenderness
☐ Normal sensation ☐ Capillary refill <3 seconds

Specific findings:
Shoulders: __________________________________
Elbows: ____________________________________
Wrists: ____________________________________
Hands: _____________________________________

Lower Extremities:
☐ Full ROM all joints ☐ 5/5 strength throughout
☐ No swelling ☐ No deformities ☐ No tenderness
☐ Normal sensation ☐ Capillary refill <3 seconds

Specific findings:
Hips: ______________________________________
Knees: ____________________________________
Ankles: ___________________________________
Feet: _____________________________________

Spine:
☐ Normal curvature ☐ No scoliosis ☐ No kyphosis
☐ Full ROM ☐ No tenderness ☐ No deformities
☐ Straight leg raise negative (if indicated)

NEUROLOGICAL EXAMINATION:

Mental Status:
☐ Alert ☐ Oriented x3 (person, place, time)
☐ Appropriate mood/affect ☐ Normal speech
☐ Follows commands ☐ Normal memory
☐ Abnormal findings: __________________________

Cranial Nerves:
I (Olfactory): ☐ Not tested ☐ Normal ☐ Abnormal
II (Optic): ☐ Visual fields normal ☐ Visual acuity tested
III, IV, VI (Oculomotor): ☐ EOMI ☐ PERRL ☐ No ptosis
V (Trigeminal): ☐ Sensation normal ☐ Jaw strength normal
VII (Facial): ☐ Facial symmetry ☐ Normal expressions
VIII (Acoustic): ☐ Hearing normal ☐ Weber/Rinne normal
IX, X (Glossopharyngeal/Vagus): ☐ Palate rises ☐ Gag reflex
XI (Accessory): ☐ SCM/trapezius strength normal
XII (Hypoglossal): ☐ Tongue midline ☐ No fasciculations

Motor Function:
☐ Normal bulk ☐ Normal tone ☐ No fasciculations
☐ 5/5 strength throughout ☐ No drift ☐ No atrophy

Reflexes:
Biceps: R___ L___ Triceps: R___ L___
Brachioradialis: R___ L___ Patellar: R___ L___
Achilles: R___ L___ Plantar: R___ L___
(Scale: 0=absent, 1=diminished, 2=normal, 3=increased, 4=hyperactive)

Sensory Function:
☐ Light touch normal ☐ Vibration normal
☐ Position sense normal ☐ Temperature normal
☐ Pain sensation normal

Coordination:
☐ Finger-to-nose normal ☐ Heel-to-shin normal
☐ Rapid alternating movements normal
☐ No dysmetria ☐ No dysdiadochokinesia

Gait:
☐ Normal gait ☐ Tandem walk normal ☐ Romberg negative
☐ Heel walk normal ☐ Toe walk normal
☐ Abnormal findings: __________________________

SKIN EXAMINATION:

General:
☐ Warm ☐ Dry ☐ Good turgor ☐ No diaphoresis
☐ Appropriate color ☐ No jaundice ☐ No cyanosis
☐ No pallor ☐ No petechiae ☐ No ecchymoses

Specific Findings:
☐ No rash ☐ No lesions ☐ No ulcerations
☐ No suspicious moles ☐ No wounds
☐ Surgical scars noted: _______________________

If lesions present:
Location: ___________________________________
Size: ______________________________________
Color: ____________________________________
Texture: __________________________________
Distribution: ______________________________

GENITOURINARY EXAMINATION (if indicated):

☐ Examination deferred ☐ Patient declined
☐ Normal external genitalia ☐ No lesions
☐ No discharge ☐ No masses ☐ No tenderness
☐ Abnormal findings: __________________________

EXAMINATION COMPLETION:

Patient comfort assessed: ☐ Comfortable ☐ Issues noted
Patient questions answered: ☐ Yes ☐ N/A
Follow-up examination needs: ☐ None ☐ Specialty referral
☐ Repeat examination ☐ Imaging studies
☐ Laboratory studies

Total examination time: _____ minutes
Examination completeness: ☐ Complete ☐ Limited by: ____

Provider signature: ___________________________
Date/Time: ___________________________________

What Specialized Physical Exam Checklists Are Available?

Different clinical specialties and patient populations require modified examination approaches that address specific assessment needs.

Pediatric Physical Exam Modifications

Include age-appropriate assessment techniques, growth and development evaluation, developmental milestones, and family interaction observations. Modify approach based on child's developmental stage and cooperation level.

Geriatric Physical Exam Considerations

Address functional assessment, cognitive screening, fall risk evaluation, and polypharmacy concerns. Include assessment of activities of daily living and social support systems.

Sports Physical Examination

Focus on cardiovascular screening, musculoskeletal assessment, injury prevention, and performance-related health factors. Include specific screening questions and examination techniques for athletic participation.

Pre-operative Physical Examination

Emphasize cardiovascular risk assessment, respiratory function evaluation, and surgical site examination. Include anesthesia-related considerations and perioperative risk stratification.

How Do I Implement Quality Assurance for Physical Examination Checklists?

Systematic quality improvement ensures consistent, comprehensive physical examinations while supporting clinical education and patient safety.

Standardization and Training

Provide comprehensive training on examination techniques, documentation requirements, and checklist utilization. Ensure consistent application across all providers and clinical settings.

Competency Assessment

Regular evaluation of examination skills through direct observation, chart review, and peer feedback. Identify areas for improvement and provide targeted education.

Template Optimization

Regular review and updates based on clinical guidelines, regulatory changes, and provider feedback. Ensure checklists remain current with evidence-based practice standards.

Outcome Monitoring

Track examination completeness, diagnostic accuracy, and patient satisfaction to assess the effectiveness of checklist implementation.

PHYSICAL EXAM CHECKLIST QUALITY INDICATORS:

✓ All required body systems examined appropriately
✓ Normal and abnormal findings clearly documented
✓ Examination technique appropriate for patient age/condition
✓ Patient comfort and dignity maintained throughout
✓ Relevant special tests performed when indicated
✓ Findings support clinical assessment and plan
✓ Provider signature and credentials documented
✓ Examination completeness verified
✓ Follow-up examination needs identified
✓ Patient questions addressed appropriately

Physical exam checklist templates provide essential structure for comprehensive patient assessment while supporting clinical education and quality improvement initiatives. Systematic examination approaches enhance diagnostic accuracy and patient safety through consistent, thorough evaluation techniques.

Explore how S10.AI's physical examination documentation platform can streamline assessment workflows, improve examination completeness, and enhance clinical accuracy in your healthcare practice.