Assessment Form Page 2
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ASSESSMENT FORM
EARS
External
Size
L
R
x
yes
no
Shape
L
R
x
yes
no
Lesions
L
no
yes
x
R
x
no
yes
Tragus
L
Mobile
yes
no
Tender
no
yes
x
R
Mobile
x
yes
no
Tender
no
yes
Meatus
L
Patent
yes
no
Discharge
no
yes
x
R
Patent
x
yes
no
Discharge
no
yes
Internal
Canal
L
Clear
x
yes
no
R
Clear
x
yes
no
Cerumen
L
Present
x
small
medium
x
large
R
Present
x
small
x
medium
large
L
Soft
yes
no Color
x
orange
R
Soft
x
yes
no Color
orange
Tympanic membrane
L
Gray
yes
no
x
R
Gray
x
yes
no
L
Lesions
x
no
yes
R
Lesions
no
yes
x
Hearing
Follows Directions
x
yes
no
Answers Questions
x
yes
no
Whisper
L
R
yes
no
_________________________ ___ _
x
Rinne
L
AC . BC
x
yes
no
R
AC . BC
x
yes
no
Weber
L
R
x
yes
no
_______ _____________________ _
Romberg
Maintains Balance
yes
no
x
NOSE
External
Midline
yes
no
x
Discharge
x
no
yes
Nares
L
Patent
x
yes
no
R
Patent
yes
no
x
Internal
L mucosa
Pink
yes
no
x
Moist
x
yes
no
Lesions
x
no
yes
R mucosa
Pink
yes
no
x
Moist
x
yes
no
Lesions
no
yes
x
Septum
Midline
x
yes
no
Intact
yes
no
x
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Parent category: Medical