General Survey Form
Objective:Â Conduct a General survey on a person of your choice. The purpose of this interaction is observation only.
1.Â Physical Appearance/Hygiene:
a. General appearance:
c. Apparent age
d. Ethnic group
e. Appears overall healthy
f. Well-groomed or disheveled (Note the general color of skin and hygiene)
2.Â Body Structure and Movement (Observe general stature)Â :
a. Height appropriate for apparent age
b. Appears well nourished
c. Weight suitable for the height
d. Position or posture (comfortable and relaxed)
e. Obvious deformities
f. Walks with ease
g. Gait balanced and smooth
h. Limitations to range of motion
i. Involuntary movements
j. Using assistive devices
3.Â Emotional/Mental Status and Behavior:
Level of alertness
Appear well rested or tired
Behavior appropriate for the situation
Dress suitable for the weather
4.Â DocumentÂ observations with detailed responses in a narrative format. For example, if a client appears tired provide a description adequate for the reader to visualize the client, â€œClient is alert and appears tired, slumped in a chair with eyes half closed.â€
5.Â DescribeÂ two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
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