GALLOP 1 of 2
Name_____________________________ Date of Birth___/__/___ Gender: Male/Female
Postnatal History (Complete or circle)
Gestation:___________weeks Birth weight:________grams APGAR 1 min____5min____
Vaginal birth: Instrumentation at birth Caesarean: Emergency/Planned
Spontaneous/Induced Forceps/Ventouse Reason:____________________
Breech: Yes/No Other health professionals
Complications_________________________________________ involved at birth or in first 14
_____________________________________________________ days:_______________________
Age of skill acquisition (record in months)
Sitting: ___________ Crawling:__________ Crawl type:__________
Walking: _________ Running:__________ Jumping:____________
History:
Medical/Family_______________ Previous treatment:______ Previous Pain:____________
___________________________ _______________________ _________________________
Footwear:___________________ Sport:__________________ Sensory concerns:_________
___________________________ _______________________ ________________________
Weight: ______kg Height: ______cm BMI:
Observation of ability to perform the following appropriate to age (Circle)
Squatting: Yes/No/NA Running: Yes/No/NA Jumping: Yes/No/N/A
Skipping: Yes/No/NA Hopping: Yes/No/NA Single Leg Stance
Left: Yes/No/N/A
Right: Yes/No/N/A
Ability to go up/down stairs: Observation of functional tasks: Quality of body movement:
Yes/No/NA __________________________ __________________________
Other Observations
_______________________________________________________________________
_______________________________________________________________________
Gait and Lower Limb Observation of Paediatrics – Standardised Recording Template (Addendum)
GALLOP 2 of 2
Pain
Biomechanical Assessments:
Left Right Left Right
Hip: Internal ROM Hip External ROM
Modified Thomas Test Hip abduction
Popliteal angle Foot thigh angle
Ankle WBL/NWB Straight Ankle WBL/NWB Bent
Foot Posture Index-6 Beighton score _______/9
Inter-condylar distance: Limb Length Discrepancy*: Other observations of rotation,
_________cm Left=Right limb length:_______________
Inter-malleoli distance: Left>Right______cm _________________________
_________cm Left<Right______cm
Neurology:
Left Right Left Right
Patella Reflex (0-4) Achilles Reflex (0-4)
Plantar Reflex (Up/down) Ankle Catch (Yes/No)
Ankle Clonus (Yes/No) Gower’s Sign
Dorsiflexion strength (0-5) Plantarflexion Strength (0-5)
Inversion strength (0-5) Eversion strength (0-5)
Observation of muscle tone or neurological signs:
Gait*
Left Right Left Right
Head and neck position Trunk/torso
Arm swing Hip
Knee Heel contact
Midstance Toe-off
Angle of gait Base of gait
Other gait comments:
Gait and Lower Limb Observation of Paediatrics – Standardised Recording Template (Addendum)
GALLOP (Addendum)
Tips for completion of free text questions instructions for podiatrists and
physiotherapists:
Ankle range of motion
The weightbearing lunge (WBL) should be performed if the child is able to put their heel to the
ground due to age specific normative values and higher reliability than the non weight bearing test
(NWB)
Observation of functional tasks:
Is the child able to perform activities appropriate to their age such as: throwing a ball, catching a ball,
kicking a ball, animal walks, sport specific activities
Quality of movement:
Does the child perform tasks symmetrically or with smooth movement? Is their movement clumsy,
jerky or asymmetrical?
Other observations of rotation, limb length*:
Presence of metatarsus adductus graded by severity and flexibility, uneven creases behind the knees
or buttocks.
Gait Observations*
Head and neck position: Tilt or lean
Trunk or torso position: Lordosis, kyphosis, tilt or lean
Arm swing: symmetry, guard position, flapping/flailing
Hip: rotation, frontal plane motion, flexion, hip drop or raise
Knee position: patella position, flexion, extension, hyperextension
Heel contact: initial contact, motion, timing, lift or rear foot position
Mid-stance: midfoot position
Toe – off: forefoot position, propulsion, symmetry, duration
Foot progression angle: Appropriate for age, too many toes
Base of gait: Narrow, scissor, wide
Other gait comments: Trendelenberg, limp, circumduction, abductory twist
* Indicate items without paediatric age-specific normative values or low reliability therefore
clinicians should use and interpret with caution
Gait and Lower Limb Observation of Paediatrics – Standardised Recording Template (Addendum)
