1 | Weight (kg) |
2 | Height (m) |
3 | Waist circumference (cm) |
4 | Hip circumference (cm) |
5 | Cyanosis Yes = 1, No = 2 |
6 | Icterus Yes = 1, No = 2 |
7 | Digital clubbing present Yes = 1, No = 2 If yes, state grade |
8 | Peripheral oedema Yes = 1, No = 2 |
9 | Pulse rate (beats/min) Pulse rhythm 1 = Regular, 2 = Regular + frequent ectopics, 3 = Regular + frequent ectopics, 4 = Regular + irregular, 5 = Irregular + irregular, 6 = Other If other, specify Pulse volume 1 = Small, 2 = Moderate, 3 = Large Arterial wall texture 1 = Normal, 2 = Hard/tortuous, 3 = Not felt Locomotor brachialis palpable? Yes = 1, No = 2 Volume of main peripheral pulses. 1 = Normal, 2 = Reduced, 3 = Absent, 4 = Increased Symmetry of main peripheral pulses 1 = Equal, 2 = Unequal Specify arteries affected |