Optional Health Assessment Modules Form Page 2
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27OPTIONAL MODULE 1:
UR Number:
PHYSICAL
Surname:
EXAMINATION
Given name:
Date of birth:
(Please fill in if no label available)
PURPOSE OF MODULE
INTRODUCTION FOR CLIENT
To assess the client’s perceived physical health.
“Now I am going to ask you about your physical health and conduct a
basic physical health check.”
WHO CAN ADMINISTER THIS MODULE?
INSTRUCTIONS
Only complete this module if you are a medical doctor or a nurse.
1. 1. Introduce module to client.
2. 2. Perform relevant tests and note down relevant information.
3. 3. Formulate responses and note actions to be taken.
VITAL SIGNS
BP:
/
HR:
RR:
SaO
(%):
BAC(%):
Temp (°C):
2
General appearance
Pupil size (please circle):
1mm
2mm
3mm
4mm
5mm 6mm (or more)
Limbs:
Systems examination
Cardiovascular (incl. Murmurs, cardiomegaly):
Respiratory
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
1
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