15 Physical Exam Templates and Guide to performing a Physical Exam

How to Perform a Physical Exam on a Patient?

A physical exam on a patient may be performed in any order and it should include an examination of all the body parts from head to toe. Usually, one can begin the exam from the head working their way down to the rest of the body.

The five components that must be included in a physical examination of a patient are:

1. Inspection: This involves a visual examination of the patient’s body for any signs of abnormality such as rashes, discolorations, swelling, or deformities.
2. Palpation: This involves using the hands to touch and feel the body for any abnormalities, such as tenderness, masses, or organ enlargement.
3. Percussion: This involves tapping the body with the fingertips to evaluate the density of underlying structures, such as the lungs or abdomen.
4. Auscultation: This involves listening to the sounds produced by the body using a stethoscope, such as heart sounds, lung sounds, or bowel sounds.
5. Vital Signs: This involves measuring the patient’s temperature, blood pressure, heart rate, and respiratory rate to assess their overall health and detect any abnormalities.

A physical exam template typically includes the following sections:

1. Vital Signs: a. Blood pressure b. Heart rate c. Respiratory rate d. Temperature e. Oxygen saturation

2. General Appearance: a. Appearance and behavior b. Nutritional status c. Signs of distress d. Skin color and texture e. Body habitus

3. Head and Neck: a. Eyes, including visual acuity and fundoscopy b. Ears, nose, and throat c. Mouth and oral cavity d. Neck, including lymph nodes and thyroid gland

4. Cardiovascular System: a. Inspection of precordium b. Palpation of the precordium and peripheral pulses c. Auscultation of the heart

5. Respiratory System: a. Inspection of the chest and respiratory rate b. Palpation and percussion of the chest c. Auscultation of the lungs

6. Gastrointestinal System: a. Inspection of the abdomen b. Auscultation of bowel sounds c. Palpation of the abdomen d. Percussion of the abdomen

7 Musculoskeletal System: a. Inspection of the extremities and joints b. Palpation of the extremities and joints c. Range of motion testing

8. Neurological System: a. Mental status examination b. Cranial nerve examination c. Sensory examination d. Motor examination e. Reflex examination

9. Genitourinary System (for males and females): a. Inspection of external genitalia b. Palpation of internal genitalia c. Digital rectal exam (for males) d. Pelvic exam (for females)

Above components are a general inclusion for a physical exam template, and the specific components may vary depending on the patient’s age, gender, and presented complaints.

Additionally, certain components may be omitted or modified based on the clinician’s discretion and clinical judgement.

Physical Exam Template Examples by Age

Physical exams are carried out in the same manner for all age groups but depending on the age and details required by the physician, the information and detail often changes. Below are some examples of physical exam templates for patients of different age groups in their detailed as well as brief version:

Physical Exam Template – Children 0-1 year old

Physical Exam Template – Children 0-1 year Detailed Version

Vital signs: Reviewed. Temperature, heart rate, respiratory rate, and oxygen saturation (if possible). General Appearance: Normal general appearance. NAD. HEENT Head: Normocephalic, no palpable masses. Eyes: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus. Ears: Normal external ears, normal TMs. Nose: Normal nares. Mouth and Throat: MMM. Normal gums, mucosa, palate. Tongue midline. Neck: Supple, with no masses. CV: Regular rhythm, no murmurs, no gallops. Lungs: Clear to auscultation bilaterally. ABD: Soft, non-tender, no masses or organomegaly. Normal bowel sounds. GU: Normal genitalia, no masses or tenderness. Skin: Warm & well perfused. No skin rashes or abnormal lesions. MSK: Normal extremities & spine. No deformities. Normal tone. No clubbing, cyanosis, or edema. Neurologic: Normal muscle strength and tone. No focal deficits. Sucking and Moro reflexes present. Growth Chart: Following growth curve well in all parameters. BMI not applicable.

Physical Exam Template – Children 0-1 year Brief Version

Vital Signs: Heart rate: 96 bpm; Respiratory rate: 22 bpm: Temperature: 98.4 F General Appearance: Normal general appearance. NAD. HEENT Head: Normocephalic. Eyes: No redness or discharge. Ears: Normal external ears. Nose: Normal nares. Mouth and Throat: MMM. Normal gums, mucosa, palate. Tongue midline. CV: Regular rhythm, no murmurs, no gallops. Lungs: Clear to auscultation bilaterally. ABD: Soft, non-tender, no masses or organomegaly. Normal bowel sounds. GU: N/A Skin: Warm & well perfused. No skin rashes or abnormal lesions. MSK: Normal tone. No clubbing, cyanosis, or edema. Normal extremities. No deformities. Neurologic: No focal deficits.

Physical Exam Template – Children 1-2 years

Physical Exam Template – Children 1-2 years Detailed Version

Vital Signs: Heart rate: 94 bpm; Respiratory rate: 23 bpm: Temperature: 98.5 F BMI: Weight: 26 pounds; Height: 34 inches. BMI: 17.4 General Appearance: Normal general appearance. NAD. HEENT Head: NC/AT. Eyes: No redness, discharge, or tearing observed. Pupils are equal, round, and reactive to light and accommodation. Ears: Bilateral normal and intact external ears. No tenderness, swelling, or discharge noted in the ear canals. Nose: Bilateral normal and patent nares with no signs of obstruction, bleeding, or discharge. Mouth and Throat: Moist, mucous membranes. Normal gums, mucosa, and palate. Teeth eruption is normal for age. Neck: Supple, with no masses. CV: RRR, no m/r/g. Lungs: CTAB, no w/r/c. ABD: Soft, non-tender, no masses or organomegaly. GU: Normal genitalia. Skin: Warm & well perfused. No skin rashes or abnormal lesions. MSK: Normal extremities & spine. No deformities. Normal gait. No clubbing, cyanosis, or edema. Neurologic: Normal muscle strength and tone. No focal deficits. Growth Chart: Following growth curve well in all parameters. BMI at 75th percentile.

Physical Exam Template – Children 1-2 year Brief Version

Vital Signs & BMI: Heart rate: 95 bpm; Respiratory rate: 22 bpm; Temperature: 98.6 F; BMI: 17.4 General Appearance: Normal general appearance, no apparent distress. HEENT Head: NC/AT. Eyes: No redness or discharge. Ears: Normal external ears. Nose: Normal nares. Mouth and Throat: MMM. Normal gums, mucosa, palate. Teeth eruption is normal for age. CV: RRR, no m/r/g. Lungs: CTAB, no w/r/c. ABD: Soft, non-tender, no masses or organomegaly. GU: N/A Skin: Warm & well perfused. No skin rashes or abnormal lesions. MSK: Normal gait. No clubbing, cyanosis, or edema. Normal extremities. No deformities. Neurologic: No focal deficits.

Physical Exam Template – Adults

Physical Exam Template – Adults Detailed Version

Vital Signs & BMI: Heart rate: 95 bpm; Respiratory rate: 22 bpm; Temperature: 98.6 F; Oxygen Saturation: 96%; BMI: 19.5 General Appearance: Alert and oriented, no acute distress. HEENT: -Head: Normocephalic, atraumatic. -Eyes: Pupils equal, round, and reactive to light. Extraocular movements intact. Fundoscopic exam normal. -Ears: Normal external ears, canals, and drums. -Nose: Patent nares, mucosa normal. -Mouth and Throat: Oral mucosa moist, no lesions. Good dentition, no pharyngeal erythema or exudate. Neck: Supple, no palpable lymph nodes or thyromegaly. CV: Regular rate and rhythm, no murmurs or gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. ABD: Soft, non-tender, no hepatosplenomegaly, no masses or organomegaly. GU: Normal external genitalia. MSK: No deformities, normal gait, full range of motion. No swelling or tenderness. Neurologic: Alert and oriented, cranial nerves intact, normal sensation and strength, no tremors or involuntary movements. PSYCH: Normal mood and affect, no suicidal or homicidal ideation, no perceptual disturbances or cognitive impairment.

Physical Exam Template – Adults Brief Version

Vital Signs & BMI: Heart rate: 95 bpm; Respiratory rate: 22 bpm; Temperature: 98.6 F; SpO2: 97%; BMI: 21.5 General Appearance: Alert and oriented, NAD. HEENT: Normocephalic, atraumatic. Eyes, ears, nose, and throat are normal. Neck: Supple, no lymphadenopathy or thyromegaly. CV: Regular rate and rhythm, no murmurs or gallops. Lungs: Clear to auscultation bilaterally. ABD: Soft, non-tender, no hepatosplenomegaly or masses. GU: Normal external genitalia. MSK: No deformities, normal gait, full range of motion. Neurologic: Alert and oriented, cranial nerves intact, normal sensation and strength.

Physical Exam Template – Adults 60+ years

Physical Exam Template – Adults 60+ years Detailed Version

Vital Signs: Heart rate: 96 bpm; Respiratory rate: 23 bpm; Temperature: 98.2 F; SpO2: 98% General Appearance: Alert and oriented. No acute distress. Skin: Warm and well perfused. No rashes, lesions or discoloration. HEENT: Head: Normocephalic, atraumatic. Eyes: Visual acuity intact. PERRLA. No scleral icterus or conjunctival injection. Ears: Normal hearing acuity. No cerumen impaction or discharge. Nose: Patent. No deformities or discharge. Mouth and Throat: Oral mucosa moist. Dentition is good. No ulcers or masses. Neck supple. No lymphadenopathy or thyroid enlargement. CV: Regular rhythm without murmurs, rubs, or gallops. No jugular venous distension. No peripheral edema. Lungs: Clear to auscultation bilaterally. No wheezing or crackles. Abdomen: Soft, non-tender, non-distended. Bowel sounds present in all quadrants. No hepatosplenomegaly or masses palpable. GU: Normal external genitalia. No masses or tenderness palpable. Bladder not distended. MSK: No clubbing, cyanosis or edema of extremities. No joint deformities. No obvious spinal deformities. Normal gait. Neurologic: Alert and oriented x3. Cranial nerves II-XII intact. Strength 5/5 throughout. No tremors or abnormal movements. Reflexes normal. PSYCH: Appropriate mood and affect. No suicidal or homicidal ideation. No hallucinations or delusions. HEME: No ecchymosis, petechiae or purpura.

Physical Exam Template – Adults 60+ years Brief Version

Vital Signs: Reviewed General Appearance: Alert and oriented. NAD. HEENT: Head: Normocephalic, atraumatic. Eyes: No redness or discharge. Ears: Normal hearing acuity. Nose: Patent. No deformities or discharge. Mouth and Throat: Oral mucosa moist. Dentition is good. No ulcers or masses. Neck supple. No lymphadenopathy or thyroid enlargement. CV: Regular rhythm without murmurs, rubs, or gallops. No jugular venous distension. No peripheral edema. Lungs: Clear to auscultation bilaterally. No wheezing or crackles. Abdomen: Soft, non-tender, non-distended. Bowel sounds present in all quadrants. No masses palpable. GU: Normal external genitalia. No masses or tenderness palpable. Bladder not distended. MSK: Normal gait. No clubbing, cyanosis, or edema of extremities. No joint deformities. No obvious spinal deformities. Neurologic: Alert and oriented x3. No focal deficits. Regenerate response

Telemedicine Physical Exam Template

When a patient needs a telemedicine physical exam during a phone visit, you can gauge the health of the patient based on what you hear over the phone or what you can observe on a video visit.

During a phone visit, for example, you can listen to normal breathing, ability to make a conversation, respond to questions, etc.

Below is a telemedicine physical exam template for a patient visiting on phone:

Physical Exam Template - Phone Visit

Patient’s Name: _________________

Date of Telephone Visit: ____________

General Appearance: The patient appears comfortable and at ease. No sign of distress or respiratory distress was noted during the telephone conversation. Mental Status: The patient is alert and oriented, with an organised thought pattern. No speech abnormalities were observed during the conversation. Respiratory System: No coughing or wheezing was audible during the phone call. No signs of respiratory distress were noted. Voice/Speech: The patient’s voice is clear and easy to understand, with no slurring of speech or other abnormalities noted. Overall, based on the telephone conversation, the patient appears to be in good general health with no significant physical exam findings. However, please note that a physical examination conducted in-person would provide more detailed and accurate information.

On a video visit, you can determine a lot of information for your telemedicine physical exam. You can get general appearance information from your observation of the patient and you can also gather a lot of other information by instructing the patient to do as you instruct.

Physical Exam Template - Video Visit

Patient’s Name: _________________

Date of Telephone Visit: _________________

General Appearance: The patient appears relaxed and comfortable. No respiratory distress or signs of distress were noted during the video call. Mental Status: The patient is alert and oriented, with an organized thought pattern. No speech abnormalities were observed during the video call. Neurological Examination: Symmetric spontaneous facial muscle movement was observed. No gross pupillary abnormality was noted. The pupils were symmetrical, and there was no tremor. Normal spontaneous muscle movement was observed in all extremities. The patient’s gait was normal. Skin Examination: No rash or skin lesions were observed on the face or anywhere else on the body. Musculoskeletal Examination: No tenderness was noted over the specific area(s) mentioned by the patient. No foreign body was observed in the area(s) of concern. There was no nail discoloration. Oral Examination: The oral examination was normal, and no tonsillar exudates were observed. Respiratory System: No coughing or wheezing was audible during the video call. No signs of respiratory distress were noted. Voice/Speech: The patient’s voice is clear and easy to understand, with no slurring of speech or other abnormalities noted.

Overall, based on the video call examination, the patient appears to be in good general health with no significant physical exam findings. However, please note that an in-person physical examination may be required to obtain a more detailed and accurate assessment.

5 Physical Exam Templates for Patients with Underlying Conditions

Physical Exam Template for a Pregnant Patient

Vital Signs: BP 120/80, HR 80 bpm, RR 16 breaths/min, Temp 98.6°F, SpO2 98% on RA General Appearance: Alert, cooperative, well-nourished, warm, dry skin, no rashes/lesions Head/Neck: Clear eyes, normal ears, no redness/discharge in nose/throat Cardiovascular: Normal precordium, strong regular pulses, normal heart sounds, no murmurs/gallops Respiratory: Symmetrical chest, clear breath sounds bilaterally, no wheezing/rales/rhonchi GI: Gravid/distended abdomen, no tenderness/masses/organomegaly, present bowel sounds Musculoskeletal: Symmetrical extremities, full ROM, no swelling/redness/deformity/tenderness/crepitus Neurological: Alert, oriented, normal mental status, intact cranial nerves, normal sensory exam/reflexes Genitourinary: Normal external genitalia, closed cervix, no tenderness, fetal heart rate 140 bpm

Physical exam template for a patient with diabetes

Vital Signs: BP 120/80 mmHg, HR 72 bpm, RR 16 bpm, Temp 98.4°F, O2 sat 98% on room air. General Appearance: Awake, alert, well-nourished with normal body habitus. Warm, dry, intact skin. Head and Neck Exam: Visual acuity 20/20, no diabetic retinopathy. Ears are normal. No redness or discharge in nose and throat. No palpable lymph nodes. Cardiovascular Exam: Regular heart sounds, strong and equal pulses. No peripheral vascular disease. Normal jugular venous pressure. Respiratory Exam: Clear lungs, symmetrical chest wall expansion, regular respiratory effort. Abdominal Exam: Soft, non-tender abdomen with present bowel sounds. No masses or organomegaly. Musculoskeletal Exam: Full joint range of motion, normal muscle strength and tone, no peripheral neuropathy. Neurological Exam: Alert and oriented, intact cranial nerves, normal reflexes, sensation and motor function within normal limits. Skin Exam: No signs of peripheral vascular disease or neuropathy. No skin breakdown.

Review of Diabetic Management: Review of glucose monitoring, medication regimen, diet and exercise, and any complications or concerns related to diabetes management can be added here.

Physical exam template for a patient with chest pain

Vital Signs: BP 130/80 mmHg, HR 86 bpm, RR 18 breaths/min, Temp 98.6°F, SpO2 97% on room air. General Appearance: Comfortable, alert, oriented with warm, dry, and normal skin color and texture. Cardiovascular: Regular heart sounds with strong, equal peripheral pulses and normal jugular venous pressure. Respiratory: Clear lungs, symmetrical chest wall expansion, and regular respiratory effort. Abdominal Exam: Soft abdomen with normal bowel sounds and no palpable masses or tenderness. Musculoskeletal: No chest wall tenderness, rib fractures or costo-chondral junction tenderness. Neurological: Alert and oriented with intact cranial nerves, reflexes, sensation, and motor function. Review of Cardiac Risk Factors: Age, sex, family history, hypertension, hyperlipidemia, smoking history, diabetes, obesity Review of Medical History: Any history of angina, myocardial infarction, pulmonary embolism, or other cardiovascular or respiratory disease Review of Medications: Any medications that could be contributing to chest pain, such as medications that can cause esophageal irritation or gastroesophageal reflux disease (GERD) Additional Diagnostic Tests: Electrocardiogram (ECG), chest X-ray, cardiac biomarkers (troponin levels), and any other diagnostic tests deemed necessary by the healthcare provider.

Physical Exam Template for a Patient with Asthma

Vital Signs: Reveal a blood pressure of 130/85, temperature of 98.1F, respiration of 32 bpm, SpO2 of 93%, and pulse of 110 bpm. General Appearance: Normal appearance for chronological age, does not appear chronically ill. HEENT: The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are clear. Neck: Trachea is midline. Thyroid is normal. The neck is supple. Negative nodes. Respiratory: Lungs are clear to auscultation bilaterally. The patient has an increased respiratory rate and wheezing is noted. There are no retractions or secondary muscle use. Cardiovascular: No jugular venous distention or carotid bruits. No increase in heart size to percussion. There is no murmur. Normal S1 and S2 sounds are noted without gallop. Abdomen: Soft to palpation in all four quadrants. There is no organomegaly and no rebound tenderness. Bowel sounds are normal. Obturator and psoas signs are negative. Genitourinary: No bladder tenderness, negative flank pain. Musculoskeletal: Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation. Neurologic: Normal Glasgow Coma Scale. Cranial nerves II through XII appear grossly intact. Normal motor and cerebellar tests. Reflexes are normal. Heme/Lymph: No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage. Psychiatric: Normal with no overt depression or suicidal ideations.

Physical Exam Template for a Patient with Hypertension

Vital Signs: blood pressure of 140/90, temperature of 98.3F, respiration of 24 bpm, SpO2 of 96%, and pulse of 75 bpm. General Appearance: Normal appearance for chronological age, does not appear chronically ill. HEENT: The pupils are equal and reactive. Funduscopic examination is normal. Posterior pharynx is normal. Tympanic membranes are clear. Neck: Trachea is midline. Thyroid is normal. The neck is supple. Negative nodes. Respiratory: Lungs are clear to auscultation bilaterally. The patient has a normal respiratory rate and no signs of consolidation are noted. Cardiovascular: No jugular venous distention or carotid bruits. No increase in heart size to percussion. There is no murmur. Normal S1 and S2 sounds are noted without gallop. The blood pressure is elevated. Abdomen: Soft to palpation in all four quadrants. There is no organomegaly and no rebound tenderness. Bowel sounds are normal. Obturator and psoas signs are negative. Genitourinary: No bladder tenderness, negative flank pain. Musculoskeletal: Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation. Neurologic: Normal Glasgow Coma Scale. Cranial nerves II through XII appear grossly intact. Normal motor and cerebellar tests. Reflexes are normal. Heme/Lymph: No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage. Psychiatric: Normal with no overt