Templates · Free template · Nursing assessment
Head-to-Toe Assessment Template
A printable head-to-toe physical assessment checklist that moves through each body system in order, with space for vital signs, findings and follow-up, so nothing is skipped on a busy shift.
The order matters
A head-to-toe assessment works through the body systematically: general survey and vital signs first, then neurological, head and neck, cardiovascular, respiratory, abdominal, genitourinary, musculoskeletal and skin. Working in the same order every time is what makes it fast and complete.
Inspection comes before palpation, percussion and auscultation, except for the abdomen, where you listen before you touch so palpation doesn't change the bowel sounds.
Record findings, not just ticks
Checkboxes speed up normal findings. Anything abnormal needs a description: size, location, colour, and what changed since the last assessment. Scores such as the Glasgow Coma Scale, a pain score, the Braden or the Morse Fall Scale belong here too, so trends are visible.
Head-to-Toe Assessment
Patient
General survey and vital signs
- Alert
- Responds to voice
- Responds to pain
- Unresponsive
Neurological
- Oriented to person
- Place
- Time
- Situation
Head, eyes, ears, nose and throat
Cardiovascular
- Regular rhythm
- Irregular
- Capillary refill < 2 s
- Peripheral pulses present
- Edema
Respiratory
- Clear bilaterally
- Crackles
- Wheeze
- Diminished
- Cough
- Shortness of breath
Abdomen and GI
- Soft
- Non-tender
- Distended
- Bowel sounds present
- Nausea / vomiting
Genitourinary
- Voiding independently
- Catheter
- Incontinence
Musculoskeletal and mobility
- Independent
- Uses aid
- Needs assistance
- Bed rest
Skin
- Intact
- Warm and dry
- Pale
- Diaphoretic
- Pressure injury
- Wound
Psychosocial
Sign-off
Template from zdrovia.ca/templates/head-to-toe-assessment-template/ · Chart it on a tablet instead, free, at zdrovia.ca · Adapt to your college's documentation standard before use.
Structured notes without the typing
Zdrovia's charting gives you note templates you can adapt to this one, outcome scores that trend across visits, and an AI Scribe that drafts the note from what you say in the room. Everything stays on one patient record, free for solo practitioners, with data stored in Canada.
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Frequently asked questions
What is the order of a head-to-toe assessment?
General survey and vital signs, then neurological, head and neck, cardiovascular, respiratory, abdomen, genitourinary, musculoskeletal and skin, finishing with psychosocial status.
How long does a head-to-toe assessment take?
A focused but complete assessment usually takes 10 to 15 minutes once the order is routine. Full admission assessments take longer.
Why auscultate the abdomen before palpating?
Palpation and percussion can stimulate bowel activity and change what you hear, so the abdomen is the one system where you listen before you touch.
Related
This template is a documentation aid, not clinical guidance. It records decisions about dosing, depth, and settings; it doesn't make them. Documentation standards vary by province and profession, so adapt it to your regulatory college's requirements.