Head to Toe Assessment Checklist: Step-by-Step Nursing Guide

100 Items

Comprehensive head to toe physical assessment checklist covering preparation, integumentary, head, ENT, neck, respiratory, cardiovascular, abdomen, musculoskeletal, and neurological systems.

Head To Toe Assessment Checklist

Complete head to toe physical assessment checklist covering all essential body systems including preparation and safety, integumentary system, head and scalp examination, ENT assessment, neck and thyroid evaluation, respiratory and cardiovascular systems, abdominal examination, musculoskeletal assessment, and comprehensive neurological evaluation for thorough patient health evaluation.

1. Preparation & Initial Overview

1Perform hand hygiene and don gloves / PPE as needed

2Verify patient identity using two identifiers

3Explain the procedure and obtain consent / cooperation

4Ensure privacy and adequate lighting

5Check the environment for safety and comfort (bed, rails, clutter)

6Ask if patient has any immediate needs (pain, restroom, hearing aids)

7Observe general appearance: posture, grooming, hygiene

8Note level of consciousness, orientation, and speech

9Assess visible signs of distress, pallor, diaphoresis

10Obtain baseline vital signs (temperature, pulse, respiration, BP, SpO₂)

2. Skin, Hair & Nails (Integumentary)

1Inspect skin color, tone, texture, moisture

2Check skin turgor / mobility (e.g. forearm, sternum)

3Look for lesions, rashes, bruises, scars, pressure areas

4Palpate skin temperature (warm, cool)

5Assess for edema (pitting or non-pitting) in extremities

6Inspect hair distribution, texture, scalp for lesions or parasites

7Check nails: shape, color, cleanliness, capillary refill

8Examine interdigital spaces (moisture, maceration)

9Inspect skin folds and under pressure points

10If wound(s) present, document size, depth, exudate, edges

3. Head & Scalp

1Inspect shape, symmetry, and size of skull / head

2Palpate skull for tenderness, lumps, depressions

3Examine scalp for lesions, masses, hair loss

4Check temporal arteries for pulse / tenderness

5Inspect facial symmetry (smile, frown, eyebrows)

6Assess scalp mobility (skin sliding)

7Inquire about headaches, dizziness, trauma

8Evaluate cranial nerve V (facial sensation, chewing)

9Assess cranial nerve VII (facial expressions)

10Evaluate jaw / temporomandibular joint (TMJ) movement, pain

4. Eyes, Ears, Nose & Throat (ENT / HEENT)

1Inspect external eye structures: lids, lashes, conjunctiva, sclera

2Test pupillary response to light (direct & consensual) and accommodation (PERRLA)

3Check extraocular movements (six cardinal fields)

4Assess visual acuity (near and far)

5Inspect external ears, palpate tragus and mastoid area

6Perform hearing test (whisper, finger rub, or tuning fork)

7Inspect nasal mucosa, septum, turbinates, patency of nares

8Inspect lips, mucous membranes, teeth, gums, tongue, palate

9Assess swallowing, gag reflex, uvula midline

10Palpate lymph nodes (preauricular, submandibular, cervical, etc.)

5. Neck & Thyroid / Lymphatics

1Inspect neck for symmetry, swelling, scars

2Palpate tracheal position (midline)

3Assess range of motion (flexion, extension, rotation, lateral bending)

4Evaluate cervical lymph nodes all levels (tenderness, enlargement)

5Palpate thyroid gland (size, nodules, tenderness)

6Ask patient to swallow while palpating thyroid

7Assess carotid arteries (palpate one side at a time)

8Auscultate carotids for bruits (if indicated)

9Test sternocleidomastoid and trapezius strength (CN XI)

10Observe for jugular venous distention (JVD)

6. Respiratory / Chest

1Inspect chest shape, symmetry, accessory muscle use, breathing effort

2Palpate chest expansion and tactile fremitus

3Percuss lung fields (resonance, dullness)

4Auscultate breath sounds (anterior, posterior, lateral)

5Note adventitious sounds (crackles, wheezes, rhonchi)

6Assess cough: presence, character, sputum

7Check for chest pain, shortness of breath

8Assess oxygen therapy devices in use (type, flow)

9Inspect for tracheal deviation or subcutaneous emphysema

10Evaluate thoracic mobility with deep breathing

7. Cardiovascular & Peripheral Vascular

1Palpate pulses bilaterally (carotid, radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis)

2Assess pulse strength, rhythm, equality

3Check capillary refill in fingers and toes

4Inspect extremities for color, temperature, edema

5Auscultate heart sounds in all key areas (aortic, pulmonic, tricuspid, mitral)

6Assess for murmurs, rubs, gallops

7Palpate precordium (thrills, heaves)

8Measure blood pressure in both arms (if needed)

9Assess venous return (varicosities, calf tenderness)

10Evaluate for signs of DVT (warmth, swelling, pain)

8. Abdomen & Gastrointestinal / Genitourinary

1Inspect contour, symmetry, skin, umbilicus

2Auscultate bowel sounds in four quadrants

3Percuss abdomen (tympany, dullness)

4Palpate lightly then deeply for tenderness, masses

5Palpate liver edge, spleen margin (if palpable)

6Assess for bladder distension

7Inquire about appetite, nausea, vomiting, bowel habits

8Ask about urinary function: frequency, pain, color, incontinence

9Assess any special devices: NG tube, catheter, ostomy

10If applicable, inspect external genitalia / perineum / anus

9. Musculoskeletal & Extremities

1Inspect extremities for symmetry, deformity, swelling

2Test range of motion (active & passive) for all joints

3Assess muscle strength (upper and lower limbs)

4Evaluate gait, balance, coordination

5Check for joint pain, crepitus, stiffness

6Assess for contractures or limitations

7Evaluate limb alignment, posture

8Test grip strength in both hands

9Assess sensations: light touch, pain, temperature, vibration

10For spine/back: inspect curvature, palpate vertebrae, test range

10. Neurologic & Mental Status

1Assess level of consciousness, orientation to person/place/time

2Evaluate speech clarity, comprehension

3Test cranial nerves (I–XII) as needed

4Assess motor function: strength, tone, posture

5Test reflexes (biceps, triceps, patellar, Achilles)

6Assess sensation (light touch, pain, vibration)

7Test cerebellar function (finger-to-nose, heel-to-shin, Romberg)

8Evaluate balance and gait (walk, heel-to-toe)

9Check for pronator drift, rapid alternating movements

10Screen for mental health: mood, affect, memory, cognition

Overall Progress

Total Progress0/100

0% complete

Checklist Progress

1. Preparation & Initial Overview0/10

2. Skin, Hair & Nails (Integumentary)0/10

3. Head & Scalp0/10

4. Eyes, Ears, Nose & Throat (ENT / HEENT)0/10

5. Neck & Thyroid / Lymphatics0/10

6. Respiratory / Chest0/10

7. Cardiovascular & Peripheral Vascular0/10

8. Abdomen & Gastrointestinal / Genitourinary0/10

9. Musculoskeletal & Extremities0/10

10. Neurologic & Mental Status0/10

Checklist Progress0 of 100 items completed

0% complete - Ready to download!

Browse More Checklists

Related Checklists

Explore more checklists in the Assessment Checklists category

Complete Kindergarten Assessment Checklist for Teachers & Parents

Comprehensive kindergarten readiness assessment checklist covering language skills, literacy, writing, math, cognitive development, motor skills, self-help, social-emotional, creative expression, and general awareness.

100 Items

Assessment Checklists

Environmental Site Assessment Checklist (Phase 1)

Comprehensive Phase 1 Environmental Site Assessment checklist for property due diligence and environmental risk evaluation.

100 Items

Assessment Checklists

Preschool Assessment Checklist for Teachers & Parents

Comprehensive developmental assessment covering motor skills, language, literacy, math, social-emotional, and cognitive development.

100 Items

Assessment Checklists

Toddler Assessment Checklist for Developmental Milestones

Comprehensive toddler milestone checklist covering physical, cognitive, language, social, and emotional development for early growth tracking.

100 Items

Assessment Checklists

Comprehensive Nursing Assessment Checklist

Thorough nursing assessment checklist covering all body systems and patient care areas to ensure accurate, consistent, and holistic patient evaluation.

100 Items

Assessment Checklists

Popular Categories

Most downloaded checklist categories

Audit Checklists

Ensure accuracy and compliance with audit checklists for business, finance, and safety. Organized tools for efficient auditing.

11 Downloads

6 Checklists

Home Checklists

Explore home checklists for cleaning, organization, safety, and maintenance. Keep your home efficient, safe, and clutter-free.

4 Downloads

6 Checklists

Assessment Checklists

Streamline evaluations with detailed assessment checklists. Ensure accuracy, consistency, and efficiency in academic, workplace, and project reviews.

4 Downloads

6 Checklists

Car Checklists

Find essential car checklists for maintenance, safety, road trips, and inspections. Stay prepared and keep your vehicle in top shape.

3 Downloads

6 Checklists

Planning Checklists

Get planning checklists for events, projects, and personal goals. Organize tasks and achieve success step by step.

2 Downloads

6 Checklists

Safety Checklists

Stay safe with checklists for workplace, home, and emergency preparedness. Reduce risks and stay ready for any situation.

2 Downloads

6 Checklists