PATIENT ASSESSMENT DETAILS

Date & Time of Assessment

Demographic Data:
a. Name:
b. Age/Gender:
c. Occupation:
d. Hand Dominance:
e. Marital Status:
f. Address:
g. Phone Number:

Chief Complaints:

HISTORY

 Present history:
 Past medical history: -

 Surgical history: -

 Family history: -

 Socio-economic history: -

 Personal history:-

 Drug history:-

 Associated Problems:-

Vital Signs

Temperature: Heart Rate: SPO2

Blood Pressure: Respiratory Rate: Pallor
OBSERVATION

 Built - Endomorph/ Ectomorph/ Mesomorph

 Skin color:

 Attitude of limbs:

 Involuntary movements:

 Synergy Pattern:

 Type/ Pattern of Respiration:

 Sign of trauma

- Presence of Scar/ Bruises

 Deformity: -

 Muscle wasting-

 Swelling: -

 Any equipment/ assistive device/tubes/catheters:

 Type/pattern of gait

 Posture: (note deviations)

- Anterior view

- Lateral view

- Posterior view
 PALPATION

Warmth:
Tenderness:
Crepitus/Abnormal sounds:
Edema:
Scar palpation:
Spasm:

Higher Mental Function Examination

Level of Consciousness (fully conscious/lethargic / obtundation/ stupor / coma)
GCS score -
Orientation:
 Person:
 Place:
 Time:

Memory:
 Immediate:
 Recent
 Remote:

MMSE score (if required) -

Speech & Communication -

Cranial Nerve Examination

Cranial nerve Findings Cranial nerve Findings

I Olfactory IV Trochlear
II Optic V Trigeminal
III Oculomotor VI Abducens
VII Facial X Vagus
 VIII Vestibulocochlear XI Accessory

IX Glossopharyngeal XII Hypoglossal

Cardio-Respiratory assessment:
Chief complaints (in term of cardio-respiratory systems):
Dyspnea scoring : NYHA/MMRC/BORG -
Chest Examination:
1. Observation of chest:
If on ventilator support – a) Mode of ventilation
b) Route of ventilation-
2. Palpation of Chest:

3. Percussion of Chest:

4. Auscultation of chest :

Pain Assessment

 Pain History -

 Onset & Duration of Occurrence:

 Location/Area:
 Intensity:

 Aggravating & Relieving factor:

 Quality of Pain:
 Deep
Kinaesthesia
Proprioception
Vibration
Cortical
Tactile discrimination
2 pt. discrimination
Stereognosis
Barognosis
Graphesthesia
Double Simultaneous
Stimulation
Sensory Grading System 0--Absent 1- Impaired 2-Normal NT--Not
Testable

Motor Examination:

RANGE OF MOTION
Active Passive End feel
Right Left Right Left
Flexion
Extension
Abduction
Shoulder
Adduction
Int. rotation
Ext. rotation
 Flexion
Elbow
Extension
Supination
Forearm
Pronation
Flexion
Wrist Extension
Radial
deviation
Ulnar
deviation
Flexion
Extension
Abduction
Hip
Adduction
Int. rotation
Ext. rotation
Knee Flexion
Extension
Dorsi flexion
Ankle Planter
flexion
Eversion
Inversion
Cervical
Spine Thoracic
Lumbar

Tone assessment:
Right Left Right Left

Flexors Hip Flexors

Extensors Extensors

Shoulder Abductors Abductors

Adductors Adductors
 Flexors Knee Flexors
Elbow
Extensors Extensors

Supinator Ankle Dorsi flexors

Forearm
Pronators Planter flexors

Flexors

Wrist Extensors

MANUAL MUSCLE TESTING (If not applicable attach VMC grading)

Right Left Right Left
Flexors Hip Flexors
Extensors Extensors
Shoulder Abductors Abductors
Adductors Adductors
Int. rotators Int. rotators
Ext. rotators Ext. rotators
Flexors Knee Flexors
Elbow
Extensors Extensors
Supinator Trunk Flexors
Forearm
Pronators Extensors

Flexors Ankle Dorsi flexors

Wrist Extensors Planter flexors
Ulnar deviation Evertors
Radial deviation Invertors
Flexors Note: -

Fingers Extensors

(in suspected injury to spinal cord attach, ISNSCI-ASIA)

REFLEX TESTING:

Deep Tendon Reflex: - Right Left Superficial Reflexes: - Right Left

Biceps Abdominal
Triceps Plantar
Supinator
Knee
Ankle

LLD:

Tightness / Contracture / Deformity:

Girth measurement:

Arm
Forearm
Thigh
Calf

FUNCTIONAL ASSESSMENT:

ADL: (if required attach FIM)

Activity In/dependent

Dressing

Combing

Bathing

Eating
 Toilet

Transfers
Balance:

Sitting - Static -

Dynamic -

Standing - Static-

Dynamic-

Reaching -

Coordination testing:

Non- Equillibrium test Right Left Equillibrium test Grade

Finger to Nose Standing

Pronation/Supination Standing with feet together

Rebound test Standing with eyes closed

Heel to shin Single leg standing

Finger to Finger Tandem standing

Tandem walking

Rhomberg’s test (if required):

Hand Functions-

Reaching

Grasping

Releasing
Gait analysis:

Activity Observation (mention ability, loss of balance

during gait, assistance required, fully
independent activity)

Walk 6m (note time)

Change in gait Gait speed(if able to, note deviations)

Gait with pivot turns

Stepping over obstacle

Gait with narrow base of support

Stair – ascending & descending

Any other deviation/observation

(Frontal & Sagittal Plane)

Mention usage of assistive device

SPECIAL TESTS:

INVESTIGATIONS:

PROBLEM LIST:
 SCALES/OUTCOME MEASURE(attach filled forms)

PROVISIONAL DIAGNOSIS:

GOALS:

SHORT TERM -

LONG TERM -

MANAGEMENT/TREATMENT PLAN:

Modality Frequency Intensity Time Type

Evidence based guidelines -

HOME PROGRAM

FOLLOW-UP (at 2 weeks; perform re-assessment after 30 days[attach re-assessment document])