Head to Toe Assessment Script
Knock, “Good morning, my name is Halle and I am your student nurse, is it okay if I come in?”
Provide privacy. Wash hands. Don gloves.
“Hi Ms. ___, can you tell me your full name and DOB? Do you have any allergies? Today I’m here
to complete a head-to-toe assessment on you, it should take about 30 minutes, is now a good
time for that?”
“Can you tell me where you are and the date and time?”
“Pt is alert & oriented x4. Sitting upright in chair, no signs of discomfort, dressed appropriately.
Pt uses no assistive devices. Expressions, speech, and memory are intact.”
*Hand urine cup*
“Do you mind going to the restroom and providing me a urine sample and putting on this
gown?”
Observe gait as pt walks away.
“Pt walks with good balance and coordination.”
Pt comes back.
Inspect urine.
“Pt voided 50cc of clear odorless yellow urine.”
PT STANDING
Musculoskeletal
Have pt stand and bend forward. Inspect spine and palpate.
“Spine is straight, nontender, no spasm.”
Bend forward/back, side/side, & twist at waist.
Move head side to side, up/down, ears to shoulders.
Arm circles, arm behind back, raise both arms, both hands behind head.
Bend and twist arm.
Bend and twist wrist.
Swing leg back.
PT SITTING
Have pt squeeze hands.
Push down on hands w feet. Point toes away/toward self. Twist sole in/out.
, “No limitation or crepitus in joints and symmetrical movement is noted in all joints. Muscles
have equal strength, no spasms.”
Cranial Nerves
“I am going to touch your face with this cotton swab. *touching pt* This will be dull and this will
be sharp, I want you to close your eyes and tell me if you feel a dull or sharp touch and where
you feel it.”
Touch 3 points on face. Pt identifies sensation & location.
“Doing the same thing but with a cotton ball, close your eyes and tell me where you feel the
touch.”
Touch 3 points on face. Pt identifies location.
“Sensation is intact at all locations touched.”
“I am going to hold something up to your nose, I want you to close your eyes and tell me what
you smell.”
Hold alcohol wipe to nose. Pt identifies smell.
“Cranial nerve 1 is intact.”
“Can you read out loud from the lowest line that you can see?”
Pt reads line.
“Cranial nerve 2 is intact.”
“Follow the tip of my pen light with just your eyes.” Pt follows light.
Do 6 cardinal signs & inward
“Look at my nose, I am going to shine the light in your eyes quickly.”
Shine in each eye & in middle
Compare pupil size to penlight.
“Cranial nerves III, IV, & VI are intact. Pupils are equal, round, reactive to light and
accomodation. Pupil size is normal. Corneal light is intact. “
“Go ahead and clench your teeth, open, and clench again.”
Feel pt jaw.
“Cranial nerve 5 is intact, no TMJ dysfunction, no crepitus.”
“Now smile... frown... puff your cheeks.”
Observe.
Knock, “Good morning, my name is Halle and I am your student nurse, is it okay if I come in?”
Provide privacy. Wash hands. Don gloves.
“Hi Ms. ___, can you tell me your full name and DOB? Do you have any allergies? Today I’m here
to complete a head-to-toe assessment on you, it should take about 30 minutes, is now a good
time for that?”
“Can you tell me where you are and the date and time?”
“Pt is alert & oriented x4. Sitting upright in chair, no signs of discomfort, dressed appropriately.
Pt uses no assistive devices. Expressions, speech, and memory are intact.”
*Hand urine cup*
“Do you mind going to the restroom and providing me a urine sample and putting on this
gown?”
Observe gait as pt walks away.
“Pt walks with good balance and coordination.”
Pt comes back.
Inspect urine.
“Pt voided 50cc of clear odorless yellow urine.”
PT STANDING
Musculoskeletal
Have pt stand and bend forward. Inspect spine and palpate.
“Spine is straight, nontender, no spasm.”
Bend forward/back, side/side, & twist at waist.
Move head side to side, up/down, ears to shoulders.
Arm circles, arm behind back, raise both arms, both hands behind head.
Bend and twist arm.
Bend and twist wrist.
Swing leg back.
PT SITTING
Have pt squeeze hands.
Push down on hands w feet. Point toes away/toward self. Twist sole in/out.
, “No limitation or crepitus in joints and symmetrical movement is noted in all joints. Muscles
have equal strength, no spasms.”
Cranial Nerves
“I am going to touch your face with this cotton swab. *touching pt* This will be dull and this will
be sharp, I want you to close your eyes and tell me if you feel a dull or sharp touch and where
you feel it.”
Touch 3 points on face. Pt identifies sensation & location.
“Doing the same thing but with a cotton ball, close your eyes and tell me where you feel the
touch.”
Touch 3 points on face. Pt identifies location.
“Sensation is intact at all locations touched.”
“I am going to hold something up to your nose, I want you to close your eyes and tell me what
you smell.”
Hold alcohol wipe to nose. Pt identifies smell.
“Cranial nerve 1 is intact.”
“Can you read out loud from the lowest line that you can see?”
Pt reads line.
“Cranial nerve 2 is intact.”
“Follow the tip of my pen light with just your eyes.” Pt follows light.
Do 6 cardinal signs & inward
“Look at my nose, I am going to shine the light in your eyes quickly.”
Shine in each eye & in middle
Compare pupil size to penlight.
“Cranial nerves III, IV, & VI are intact. Pupils are equal, round, reactive to light and
accomodation. Pupil size is normal. Corneal light is intact. “
“Go ahead and clench your teeth, open, and clench again.”
Feel pt jaw.
“Cranial nerve 5 is intact, no TMJ dysfunction, no crepitus.”
“Now smile... frown... puff your cheeks.”
Observe.
