fisio / b.pen. 2 / Pind.

2 / 2019
KEMENTERIAN KESIHATAN MALAYSIA
PHYSIOTHERAPY DEPARTMENT
STROKE ASSESSMENT FORM

Name :------------------------------------------ Age: --------- Sex: M / F RN /IC : ------------------------Date :-----------------

DIAGNOSIS

DOCTOR’S MANAGEMENT

CHIEF COMPLAINT/ PROBLEM

VITAL SIGNS:
BP: HR:
RR: SPO2 :

SPECIAL QUESTIONS
General Condition / Health :

PMHX / Surgery :
PAST HISTORY
Investigation : Previous Stroke: Y / N

Medication : Previous mobility: normal / limited

Home / Social Situation Comments:

(Pre-current episode): Home care independent / Home care
dependent / Home alone
(current status) : Home care independent / Home care
dependent / Home alone OBSERVATION
General :
Incontinence: Bladder Y / N
Bowel Y / N Local :

Occupation: Hobby: Dominant hand: R / L

Posture:
CURRENT HISTORY
Mobility:
Type of stroke:
OBJECTIVE
Site of lesion: Cortical / Subcortical / BrainStem / Cerebellar / Mental /Cognitive Impairment :

Others:________________ Communication Impairment: Expressive / Receptive / None

Motor Deficit: Right / Left / Bilat / either Visual Field impairment: NAD/Diplopia/Hemianopia

Date of onset: Hearing impairment: Y / N

SENSATION
COORDINATION:
Light touch: NAD / Impaired / absent
Finger to Nose : NAD/ Dysmetria
Pin Prick: NAD / Impaired /absent
Heel to Shin : Ataxia / No ataxia
Thermal sensation: NAD / Impaired /absent

GAIT PATTERN
MUSCLE TONE (Modified Asworth Scale 0 - 4)
UL:

LL:

Tendon Reflexes
UL: PHYSIOTHERAPIST’S IMPRESSION

LL:

Comment:

PROPRIOCEPTION (State the impaired joint)

SHORT TERM GOALS
UL: NAD / Impaired :……………………………………………….

LL: NAD / Impaired :……………………………………………….

RANGE OF MOTION (State the Impaired joint)

Upper Limb:……………………………………………………………………………..
LONG TERM GOALS

Lower Limb:……………………………………………………………………………..

COMPLICATIONS / OTHERS

Painful Shoulder :Y/N

Pain score Pre: Post : PLAN OF TREATMENT

Subluxed Shoulder : Y / N

Chest Complication : Y / N

Oro-Facial Function : Y / N

Comment:
OUTCOME MEASURES (Choose the applicable)

Score Remarks
Motor Assessment
Scale
Berg Balance Scale

Modified Barthel Attending Physiotherapist: ………………………..……….

Index Date : Sign & Stamp
Time Up and Go
 KEMENTERIAN KESIHATAN MALAYSIA
GUIDELINES FOR THE USE OF STROKE ASSESSMENT FORM
DIAGNOSIS
• As in referral

DOCTOR'S MANAGEMENT
• In brief, conservative or operative

PROBLEM
• What is the presenting problem?
• Functional activity, pain, stiffness, weakness ….etc.
 Patient’s Aim

CHECK THE VITAL SIGN

SPECIAL QUESTIONS
General Condition / Health
• General unwell, emotional and psychological status.

PMH / Surgery
• Other medical illness and treatment .

Ix ( Investigation)
• X-Ray, MRI, CT scan, Blood Test , if relevant

Medication
• Note medication and its side effects and effects during physiotherapy intervention.
• Precautions to be taken.

Home / Social Situation

• Is patient home carer independent, home carer dependent, home alone ………etc.
• ?flat, bungalow, house
• Changes in ADL because of condition .

Incontinence: Bladder / Bowel Control

• Ability / inability to control.

Occupation
• Nature of work, what it entails, ability to cope.

Hobby
• Leisure or recreation

CURRENT HISTORY
• Type of stroke - haemorrhagic , infarction or embolism / trombotic .
• Site of lesion - cortical , subcortical , brainstem , cerebellar or others .
• Onset - when it occurred .
• Motor deficit - effected limbs , R or L or bilateral or neither

PAST HISTORY
• Pathology with bearing on current condition.
• Has it occurred before ( ? episode ). ( eg: TIA ).
• Onset / progression , physiotherapy treatment and result ?
• Previous mobility: limited or not .

OBSERVATION.

Dominant Hand
• Hand that patient uses more frequently during activity ( ADL ), note L or R .

Posture
• General posture, look for slouching, uneven weight distribution in sitting, standing and walking

Mobility
• Dependency, wheelchair, walking aids

Others
• Skin condition, swelling, deformity, etc.

OBJECTIVE

Mental / Cognitive Impairment

• To test patient's disorientation to place , time , people and surrounding by asking simple questions / Mini Mental
State Test/MoCA

Visual Field Impairment

• To check for any visual deficit eg : L or R hemianopia , diplopia , etc.

Hearing Impairment
• To check for any hearing deficit eg : true deafness or / without hearing aids etc.

SENSATION
•Test dermatomes for light touch , pin prick and thermal sensation.

MUSCLE TONE
• Test the tone of muscles in UL and LL using Modified Asworth Scale
0: no increase in muscle ttone
1: slight increase in muscle tone, catch and release by minimal resistance at the end of range
1+: slight increase in muscle tone, catch, and followed by minimal resistance throughout the range
2: more mark increase in muscle tone, easily moved
3: increase in muscle, passive movement is difficult
4: affected part is rigid in flexion or extension

Tendon jerk for UL (biceps,brachioradialis, extensor radialis Longus)

UL and LL (patella, TA)

PROPRIOCEPTION
•Test for joint sense of UL and LL.

RANGE OF MOTION
• To note varying degrees of motor dysfunction resulting in poverty of movement and loss of function.

COMPLICATION / OTHERS
• Check for complication
MOTOR ASSESSMENT SCALE
• Attached appendix MAS. Note the score.

BERG BALANCE SCALE

• Attached appendix BBS. Note the score.

TIMED UP AND GO TEST

• Attached appendix TUG. Note the score.

MODIFIED BARTHEL INDEX

• Attached appendix MBI. Note the score.

COORDINATION
• Test the coordination

GAIT Pattern
• Analyse any abnormality and missing components in stance phase/swing phase.

PHYSIOTHERAPIST'S IMPRESSION
• Problem (s) according to activity impairment

SHORT TERM GOALS

• The goals which are set according to priority.
• Must include the expected outcomes and time frame.

LONG TERM GOALS

• The goals which are set for a longer time frame based on patient goals and physiotherapist's goals.

PLAN OF TREATMENT
• The physiotherapist treatment that will be given accordingly to the goals set up.

SIGN/ STAMP/DATE :
● Need to be filled by attending physiotherapist
 MOTOR ASSESSMENT SCALE
Name: ____________________R/N :_______________ I/C :_________________Date: _________________

Supine to side-lying onto intact side Supine to sitting over side of bed
1 Pulls himself into side-lying position. 1 Side-lying position, lifts head sideways but can't sit
(Starting position must be supine, not knee- up. (Patient assisted to side-lying position).
flexed). Patient pulls himself into side-lying
position with intact arm, moves affected leg with
intact leg.
2 Active moves leg across and lower half of body 2 Side-lying position to sitting over sde of bed.
follows. (Starting position as above. (Therapist assists patient with movement. Patient
Arm is left behind). controls head position throughout).

3 Arm is lifted across body with other arm. Leg is 3 Side-lying posotion to sitting over side of bed.
moved actively and body follows in a block. (Therapist gives stand-by help [see instructions] by
(Starting position as above). assisting legs over side of bed).

4 Moves arm across body actively and the rest of 4 Side-lying position to sitting over side of bed. (With
the body moves as a block. (Starting position as no stand-by help).
above).

5 Moves arm and leg and rolls to side but 5 Supine to sitting over side of bed. (With no stand-by
overbalances. (Starting position as above. help).
Shoulder protracts and arm flexes forward)
6 Rolls to side in 3 seconds. (Starting position as 6 Supine to sitting over side of bed within 10 seconds.
above. Must not use hands). (With no stand-by help).

Balanced sitting Sitting to standing

1 Sits only with support. (Therapist should assist 1 Gets to standing with help from therapist. (Any
patient into sitting). method).
2 Sits unsupported for 10 seconds. (Without holding 2 Gets to standing with stand-by help. (Weight
on, knees and feet together, feet can be unevenly distributed, use hands to support).
supported on the floor).
3 Sits unsupported with weight well forward and 3 Gets to standing. (Do not allow uneven weight
evenly distributed. (Weight should be well distribution or help from hands).
forward at the hips, head and thoracic spine
extended; weight evenly distributed on both
sides).
4 Sits unsupported, turns head and trunk to look 4 Gets to standing and stands for 5 seconds with hips
behind. (Feet supported and together on the and knees extended. (Do not allow uneven weight
floor. Do not allows legs to abduct or feet to distribution).
move. Have hands resting on thighs, do not allow
hands to move onto plinth).
5 Sits unsupported, reaches forward to touch the 5 Sitting to standing to sitting with no stand-by help.
floor, and retuns to starting position. (Feet (Do not allow uneven weight distribution. Full
supported on the floor. Do not allow patient to extension of hips and knees).
hold on. Do not allow legs and feet to move,
support affected arm if necessary. Hand must
touch floor at least 10 cm [4 in] in front to feet).
6 Sits on stool unsupported, reaches sideways to 6 Sitting to standing to sitting with no stand-by help
touch floor, and returns to starting position. (Feet three times in 10 seconds. (Do not allow uneven
supported on floor. Do not allow patient to hold weight distribution).
on. Do not allow legs and feet to move, support
affected arm if necessary. Patient must reach
sideways and not forward).
 Walking Upper arm function
1 Stands on affected leg and steps forward with 1 Lying, protract shoulder girdle with arm in elevation.
other leg. (Weight bearing hip must be extended. (Therapist places arm in position and support it with
Therapist may give stand-by help). elbow in extension).

2 Walks with stand-by help from one person. 2 Lying, hold extended arm in elevation for 2 seconds.
(Therapist should place arm in position and patient
must maintain position with external rotation. Elbow
must be held within 20 degree of full extension).

3 Walks 3 m (10 ft) alone or uses an aid but no 3 Flexion and extension of the elbow to take palm to
stand-by help). forehead with arm as in #2. (Therapist may assist
supination of forearm).
4 Walks 4 m (13 ft) with no aid in 15 seconds. 4 Sitting, hold extended arm in forward flexion at 90
degree to body for 2 seconds. (Therapist masy assist
supination of forearm).
5 Walks 10 m (33ft) with no aid, turns around, pick 5 Sitting, patient lifts arm to above position, holds it
small sand bag from the floor, and walks back in there for 10 seconds, and then lower it. (Patient must
25 seconds. (May use either hand). maintain position with external rotation. Do not
allow pronation).
6 Walks up and down four steps with or without an 6 Standing, hand against wall. Maintain arm position
aid but without holding on the rail three times in while turning body toward wall. (Have arm abducted
35 seconds. to 90 degree with palm flat against wall).

Hand movements Advanced hand activities

1 Sitting, extension of wrist. (Therapist should have 1 Picking up the top of a pen and putting it down again.
patient sitting at table with forearm resting on (Patient stretches arm forward, picks up pen top,
table. Therapist places cylindrical object in palm of releases it on the table close to body).
patient's hand. Patient is asked to lift object off
table by extending the wrist. Do not allow elbow
flexion).

2 Sitting, radial deviation of the wrist. (Therapist 2 Picking up one jellybean from a cup and placing it in
should place forearm in mid pronation-supination, another cup. (Teacup contains eight jellybeans. Both
fingers around a cylindrical object. Patient is asked cups must be at arms length. Affected hand takes
to lift object off the table. Do not allow elbow jellybean from cup on the opposite side and release
flexion or pronation). in the cup on the affected hand's side).

3 Sitting, elbow into side, pronation and supination. 3 Drawing horizontal lines to stop at vertical line 10
(Elbow unsupported and at right angle. Three- times in 20 seconds. (At least 5 lines must touch and
quarter range is acceptable). stop at vertical line).

4 Reach forward, pick up a large ball of 14 cm [5 in] 4 Holding a pencil, making rapid consecutive dots on a
diameter with both hands and put it down. (Ball sheet of paper. (Patient must make at least 2 dots
should be on table so far in front of patient that per second for 5 seconds. Patient picks a pencil up
he has to extend arms fully to reach it. Shoulder and position it without assistance. Patient must make
must be protracted, elbows extended, wrist a dot and not a stroke).
neutral or extended. Palms should be in contact
with the ball).

5 Pick up polystyrene cup from table and put it on 5 Taking a dessert spoon of liquid to the mouth. (Do
table across other side of body. (Do not show not allow head to lower towards spoon. Do not allow
alteration in shape of the cup). liquid to spill).

6 Continuous opposition of the thumb with each 6 Holding a comb and combing hair to back of head.
finger more than 14 times in 10 seconds. (Each
finger turn taps thumb, starting with index finger.
Do not allow thumb to slide from one finger to the
other, or to go backwards).
 BERG BALANCE SCALE
14-Item Long Form Original Version

Name: _________________________
Rater: _______________________ Date: _____________________

In most items, the subject is asked to maintain a given position for a specific time. Progressively more points are deducted if the
time or distance requirements are not met, if the subject's performance warrants supervision, or if the subject touches an
external support or receives assistance from the examiner. Subjects should understand that they must maintain their balance
while attempting the tasks. The choices of which leg to stand on or how far to reach are left to the subject. Poor judgment will
adversely influence the performance and the scoring.
Equipment required for testing are a stopwatch or watch with a second hand, and a ruler or other indicator of 2, 5 and 10 inches
(5, 12 and 25 cm). Chairs used during testing should be of reasonable height.

1. SITTING TO STANDING 6. STANDING UNSUPPORTED WITH EYES CLOSED

INSTRUCTIONS: Please stand up. Try not to use your hands for INSTRUCTIONS: Please close your eyes and stand still for 10
support. seconds
(4) Able to stand without using hands and stabilize
independently (4) Able to stand 10 seconds safely
(3) Able to stand independently using hands (3) Able to stand 10 seconds with supervision
(2) Able to stand using hands after several tries (2) Able to stand 3 seconds
(1) Needs minimal aid to stand or to stabilize (1) Unable to keep eyes closed 3 seconds but stays steady
(0) Needs moderate or maximal assist to stand (0) Needs help to keep from falling

2. STANDING UNSUPPORTED 7. STANDING UNSUPPORTED WITH FEET TOGETHER

INSTRUCTIONS: Please stand for 2 minutes without holding. INSTRUCTIONS: Place your feet together and stand without
(4) Able to stand safely for 2 minutes holding
(3) Able to stand 2 minutes with supervision (4) Able to place feet together independently and stand 1
(2) Able to stand 30 seconds unsupported minute safely
(1) Needs several tries to stand 30 seconds unsupported (3) Able to place feet together independently and stand for 1
(0) Unable to stand 30 seconds un assisted. If a subject is able minute with supervision
to stand 2 minutes unsupported, score full points for sitting (2) Able to place feet together independently but unable to
unsupported. Proceed to item #4. hold for 30 seconds
(1) Needs help to attain position but able to stand 15 seconds
3. SITTING WITH BACK UNSUPPORTED BUT FEET feet together
SUPPORTED ON FLOOR OR ON A STOOL (0) Needs help to attain position and unable to hold for 15
INSTRUCTIONS: Please sit with arms folded for 2 minutes. seconds
(4) Able to sit safely and securely 2 minutes
(3) Able to sit 2 minutes under supervision 8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE
(2) Able to sit 30 seconds STANDING
(1) Able to sit 10 seconds INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your
(0) Unable to sit without support 10 seconds fingers and reach forward as far as you can. (Examiner places
a ruler and end of fingertips when arm is at 90 degrees.
4. STANDING TO SITTING Fingers should not touch the ruler while reaching forward. The
recorded measure is the distance forward that the finger
INSTRUCTIONS: Please sit down.
reaches while the subject is in the most forward lean position.
(4) Sits safely with minimal use of hands When possible, ask subject to use both arms when reaching to
(3) Controls descent by using hands avoid rotation of the trunk.)
(2) Uses back of legs against chair to control descent
(1) Sits independently but has uncontrolled descent (4) Can reach forward confidently > 25 cm (10 inches)
(0) Needs assistance to sit (3) Can reach forward > 12 cm safely (5 inches)
(2) Can reach forward > 5 cm safely (2 inches)
(1) Reaches forward but needs supervision
(0) Loses balance while trying/requires external support
5. TRANSFERS
INSTRUCTIONS: Arrage chair(s) for a pivot transfer. Ask
subject to transfer one way toward a seat with armrests and 9. PICK UP OBJECT FROM FLOOR FROM A STANDING
one way toward a seat without armrests. You may use two POSITION
chairs (one with and one without armrests) or a bed and a INSTRUCTIONS: Pick up shoes/slipper which is placed in front
chair of your feet.

(4) Able to transfer safely with minor use of hands

(3) Able to transfer safely definite need of hands (4) Able to pick up slipper safely and easily
(2) Able to transfer with verbal cueing and/or supervision (3) Able to pick up slipper but need supervision
(1) Needs one person to assist (2) Unable to pick up but reaches 2-5 cm (1-2 inches) from
(0) Needs two people to assist or supervise to be safe slipper and keeps balance independently
(1) Unable to pick up and needs supervision while trying
(0) Unable to try/needs assist to keep from losing balance or
falling

10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT 13. STANDING UNSUPPORTED ONE FOOT IN FRONT
SHOULDERS WHILE STANDING INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot
INSTRUCTIONS: Turns to look directly behind you over toward directly in front of the other. If you feel that you cannot place
left shoulder. Repeat to the right. Examiner may pick an your foot directly in front, try to step far enough ahead that
object to look at directly behind the subject to encourage a the heel of your forward foot is ahead of the toes of the other
better twist turn. foot. (To score 3 points, the length of the step should exceed
the length of the other foot and the width of the stance
(4) Looks behind from both sides and weight shifts well
should approximate the subject's normal stride width).
(3) Looks behind one side only other side shows less weight
shift (4) Able to place foot tandem independently and hold 30
(2) Turns sideways only but maintain balance seconds
(1) Needs supervision when turning (3) Able to place foot ahead of other independently and hold
(0) Needs assist to keep from losing balance or falling 30 seconds
(2) Able to take small step independently and hold 30 seconds
11. TURN 360 DEGREES
INSTRUCTIONS: Turns completely around in a full circle. (1) Needs help to step but can hold 15 seconds
Pause. Then turn a full circle in the other direction
(4) Able to turn 360 degress safely in 4 seconds or less (0) Loses balance while stepping or standing
(3) Able to turn 360 degress safely one side only in 4 seconds
or less 14. STANDING ON ONE LEG
(2) Able to turn 360 degress safely but slowly INSTRUCTIONS: Stand on one leg as long as you can without
(1) Needs close supervision or verbal cuieing holding.
(0) Needs assistance while turning (4) Able to lift leg independently and hold > 10 seconds
(3) Able to lift leg independently and hold 5-10 seconds
12. PLACING ALTERNATE FOOT ON STEP OR STOOL WHILE (2) Able to lift leg independently and hold = or > 3 seconds
STANDING UNSUPPORTED (1) Tries to lift leg unable to hold 3 seconds but remains
INSTRUCTIONS: Place each foot alternately on the step/stool. standing independently
Continue until each foot has touched the step/stool four (0) Unable to try or needs assist to prevent fall
times.
(4) Able to stand independently and safely and complete 8
steps in 20 seconds
(3) Able to stand independently and safely and complete 8
steps > 20 seconds
(2) Able to complete 4 steps without aid with supervision
(1) Able to complete > 2 steps needs minimal assist
(0) Needs assistance to keep from falling/unable to try

( ) TOTAL SCORE (Maximum = 56), a person scoring below

45 is considered to be at risk for falling
 Timed Up and Go (TUG) Test

1. Equipment: arm chair, tape measure, tape, stop watch.

2. Begin the test with the subject sitting correctly (hips all of the way to the back of the seat) in a chair with arm

rests. The chair should be stable and positioned such that it will not move when the subject moves from sit to stand.

The subject is allowed to use the arm rests during the sit – stand and stand – sit movements.

3. Place a piece of tape or other marker on the floor 3 meters away from the chair so that it is easily seen by the

subject.

4. Instructions: “On the word GO you will stand up, walk to the line on the floor, turn around and walk back to the

chair and sit down. Walk at your regular pace.

5. Start timing on the word “GO” and stop timing when the subject is seated again correctly in the chair with their

back resting on the back of the chair.

6. The subject wears their regular footwear, may use any gait aid that they normally use during ambulation, but may

not be assisted by another person. There is no time limit. They may stop and rest (but not sit down) if they need to.

7. Normal healthy elderly usually complete the task in ten seconds or less. Very frail or weak elderly with poor

mobility may take 2 minutes or more.

8. The subject should be given a practice trial that is not timed before testing.

9. Results correlate with gait speed, balance, functional level, the ability to go out, and can follow change over

time.
Modified Barthel ADL index* Measure of physical disability used widely to assess behaviour relating to

activities of daily living for stroke patients or patients with other disabling conditions. It measures what

patients do in practice. Assessment is made by anyone who knows the patient well.

Bowels 0 = Incontinent or needs enemas Transfer (bed to chair and back) 0 = Unable, no sitting

1 = Occasional accident (1x/wk) balance

2 = Continent 1 = Major help (1 or 2 people), can sit

2 = Minor help (verbal or physical)

3 = Independent

Bladder 0 = Incontinent or needs enemas Mobility 0 = Immobile

1 = Occasional accident (1x/wk) 1 = Wheelchair independent (including corners)

2 = Continent 2 = Walks with the help of 1 person (physical or verbal

help)

3 = Independent (may use aid)

Grooming 0 = Needs help with personal care Dressing 0 = Dependent

1 = Independent (including face, hair, teeth, shaving 1 = Needs help – can do ~ ½ unaided

2 = Independent (including buttons, zips, laces, etc.)

Toilet Use 0 = Independent Stairs 0 = Unable

1 = Needs some help 1 = Needs help (verbal or physical)

2 = Independent 2 = Independent

Feeding 0 = Unable Bathing 0 = Dependent

1 = Needs help, e.g. cutting 1 = Independent (bath or shower)

2 = Independent