GCU Head-to-Toe Skills Check Off
1. Perform Initial Approach and History Taking - ANS Introduce self, identify role, explain intent
for exam, gather supplies, and wash hands. 1
Obtain patient identification information: age, gender, race, date of birth. 1
Describe the chief complaint in a short sentence using the patient's own words. 1
Complete an HPI workup using OPQRST (onset, provocative or palliative, quality or quantity,
region or radiation, severity, and timing). 3
2. Verbally Obtain Past Medical History - ANS General health—include last dates/findings of
exams 1
Chronic illness—what, when, how treated 1
Psychiatric—diagnosis, treatment, hospitalization 1
Infectious diseases 1
Allergies/Medications 1
Surgery—type, complications, anesthesia 1
Injuries and previous hospitalizations 1
Immunizations 1
Female—GYN 1
Male and Female—Sexual history, partners, sexual practices, past history of STI, protection
from STI, pregnancy plans 1
3. Verbally Obtain Family History - ANS Grandparents, parents, siblings, children—health
status, age, cause of death 1
HEENT 1
CVD 1
Neurological 1
Pulmonary 1
GI 1
GU 1
Endocrine 1
MS 1
Obesity 1
Cancer 1
Bleeding Disorders 1
Mental/Emotional 1
Genetic Disorders 1
Substance Abuse 1
Allergies 1
4. Verbally Obtain Social History - ANS Place of birth 1
, Nationality/Ethnicity 1
Marital status/Significant other 1
Occupation 1
Military history 1
Social and economic status—living arrangements 1
Habits—diet (include any restrictions), hydration, nutritional status, exercise, laxative use,
caffeine use 3
Tobacco/Alcohol/Drug use 1
Emotional/Stress/Sleep 1
Hobbies/Leisure activities 1
Alternative health care practices 1
Violence and safety 1
5. Verbally Obtain Review of Systems - ANS Constitutional—overall health 2
Eyes—changes in vision, blurred vision, floaters, etc., and last eye exam 2
ENT/Mouth - changes/difficulty in hearing, ear pain or discharge, change/difficulty smelling,
runny nose, sore throat, problem swallowing, difficulty eating/chewing foods, sores or lesions in
the mouth, and last dental exam 2
Cardiovascular—Chest pain, abnormal heart beats, skipped beats, fluttering, shortness of
breath with/without exertion 2
Respiratory—difficulty breathing, cough 2
GI—daily bowel movement (quantity and quality), diarrhea or constipation, blood in the stool 2
GU—difficult or painful urination, discharges or pain 2
M/S—painful joints or muscles, problems with range of motion 2
Skin/Breasts—changes in the skin, dryness, rashes, lesions, nodules 2
Neurologic—dizziness, blurred vision, unsteady gait 2
Psychiatric—depression, anxiety, sleep 2
Endocrine—hot or cold, sweaty, hair, weight loss or gain 2
Hem/Lymph—bruising easily, taking a long time to heal, getting sick easily 2
Allergic/Immunologic—allergic to any foods or other substances 2
6. Perform Initial Physical Exam: General Survey - ANS General appearance
(verbalized)—physical appearance/state of health, ease of breathing, nutritional status, posture,
hygiene, odors, mobility,
General appearance (verbalized)—physical appearance/state of health, ease of breathing,
nutritional status, posture, hygiene, odors, mobility, attentiveness/attitude and expression, LOC,
orientation, affect and mood, signs of distress or illness 2
Obtain height and weight 1
Assess vital signs—BP, HR, R, T 1
Assess for visual acuity (CN II) 1
Display of overall technical skill during the initial physical exam 2