Geriatric Physical Examination Form
Patient Information
Name:
Date of Birth:
Medical Record #:
Exam Date:
Vital Signs
Blood Pressure:
Heart Rate:
Temperature:
Respiratory Rate:
Height:
Weight:
General Appearance
Appearance:
Level of Consciousness:
Head, Eyes, Ears, Nose, Throat (HEENT)
Head:
Eyes:
Ears:
Nose:
Throat:
Neck
Neck Examination:
Cardiovascular
Heart Sounds:
Peripheral Pulses:
Edema:
Respiratory
Lung Sounds:
Effort/Breathing Pattern:
Abdomen
Inspection:
Palpation (Tenderness, Mass):
Bowel Sounds:
Musculoskeletal
Joints:
Muscle Strength:
Neurological
Orientation:
Reflexes:
Gait/Balance:
Skin
Condition:
Other Findings / Notes