Neurological Physiotherapy Evaluation Form

I.

Subjective Assessment

Demographics: Name: S/o, D/o, W/o: Age: -

Marital Status: -

Gender: -

Language: Occupation: Address: Time of Admission: -

Mode of Admission: -

Presenting Complaint: -

HOPC: ____________________________________________________________________________________
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Past Medical History:

Medical:__________________________________________________________________
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Surgical:_________________________________________________________________
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Treatment History:
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Family History:
________________________________________________________________________
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Socioeconomic History:
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Symptoms History:
- Side:

- Site:

- Onset:

- Duration:

- Type:

- Severity:

- Aggravating Factors:
- Relieving Factors:
Vital Signs:
- Temperature:
- Blood Pressure:

II.

- Heart Rate:
- Respiratory Rate:

Objective Examination:

a) ON OBSERVATION:
- Attitude of limbs:
- Built:
- Posture:
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- Gait: ______________________________________________________________
- Pattern of Movement:_________________________________________________
- Mode of Ventilation:__________________________________________________
- Type/ Pattern of Respiration:___________________________________________
- Oedema: ___________________________________________________________
- Muscle Wasting: _____________________________________________________
- Pressure Sores:______________________________________________________
- Deformity:_________________________________________________________
- Wounds:___________________________________________________________
- External Appliances: ________________________________________________
b) ON EXAMINATION
HIGHER MENTAL FUNCTIONS
Level of Consciousness:_______________________________________________________
Orientation: ______________________________________

- Person:________________________________
- Place:_________________________________
- Time:__________________________________
Memory:

- Immediate:__________________________________
- Recent:______________________________________
- Remote:_____________________________________
Speech:____________________________________________________________________
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 Cognition:

- Fund of Knowledge: _____________________________________________________

- Calculation:____________________________________________________________
- Proverb Interpretation:___________________________________________________
Attention:__________________________________________________________________
Emotional Status:____________________________________________________________
Perception:_________________________________________________________________
Agnosias/ Apraxias:__________________________________________________________

Cranial Nerves:
Nerves

Comments

I - Olfactory
II - Optic
III - Oculomotor
IV - Trochlear
V - Trigeminal
VI - Abducent

Nerves

Comments

VII - Facial
VIII - VestibuloCochlear
IX - Glossopharyngeal
X - Vagus
XI - Accessory
XII - Hypoglossal

SENSORY SYSTEM:
Upper
Extremity

Location
Sensation

Rt

Lt

Lower
Extremity
Rt

Lt

Trunk
Rt

Comments

Lt

Superficial
Pain
Temperature
Touch
Pressure
Deep
Mov. Sense
Pos. Sense
Vibration
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Cortical
Tactile Localization
2 pt. discrimination
Stereognosis
Barognosis
Graphesthesia
Texture Recognition
Double
Simultaneous
Stimulation

MOTOR SYSTEM:
Muscle Girth:
Area

Rt

Lt

Arm
Forearm
Thigh
Calf

Voluntary Control:
Side

Rt

Lt

Upper Limb
Lower Limb
Myotomes: -

Myotomes Root
C1/C2
C3
C4
C5
C6
C7
C8
T1
L2
L3
L4
L5
S1
S2

Function
neck flexion/extension
neck lateral flexion
shoulder elevation
shoulder abduction
elbow flexion/wrist extension
elbow extension/wrist flexion
thumb extension
finger abduction
hip flexion
knee extension
ankle dorsi flexion
great toe extension
ankle plantar flexion
knee flexion

Comment

Range of Motion:
Side
Upper Limb

Rt

Lt

Lower Limb

Limb Length:
Side

Rt.(cm.)

Lt.(cm.)

True
Apparent

Muscle Tone:
Muscles
Shoulder
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Elbow
Flexors
Extensors
Forearm
Pronators
Supinators
Wrist
Flexors
Extensors
Radial Deviators
Ulnar Deviators
Hand
Intrinsics
Extrinsics

Rt

Lt

Muscles
Hip
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Knee
Flexors
Extensors
Ankle
Dorsiflexors
Plantarflexors
Foot
Invertors
Evertors
Intrinsics
Extrinsics
Remarks:

Rt

Lt

Muscle Power:
Muscles
Shoulder
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Elbow
Flexors
Extensors
Forearm
Pronators
Supinators
Wrist
Flexors
Extensors
Radial Deviators
Ulnar Deviators
Hand
Intrinsics
Extrinsics

Rt

Lt

Muscles
Hip
Flexors
Extensors
Abductors
Adductors
External Rotators
Internal Rotators
Knee
Flexors
Extensors
Ankle
Dorsiflexors
Plantarflexors
Foot
Invertors
Evertors
Intrinsics
Extrinsics

Rt

Lt

Trunk Flexors
Trunk Extensors
Trunk Side Flexors
Trunk Rotators

Reflexes:

Superficial
Deep

Reflex
Abdominal
Plantar

Right

Left

Biceps
Brachioradialis
Triceps
Knee
Ankle

Coordination:
Non Equilibrium Tests
Finger to nose
Finger opposition
Mass Grasp
Pronation/Supination

Rt

Lt

Equilibrium tests
Standing: Normal Posture
Standing: Normal Posture with
vision occluded
Standing: Feet together

Rebound test

Standing on one foot

Tapping (Hand)

Standing: Lateral trunk flexion

Tapping (Foot)

Tandem walking

Heel to knee
Drawing a circle (Hand)
Drawing a circle (Foot)

Grade

Walk: Sideways
Walk: Backward
Walk in Circle
Walk on Heels
Walk on Toes

Involuntary Movements:
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Balance:

- Sitting:__________________________________________________________________
- Standing:________________________________________________________________
- Balance Reactions:________________________________________________________
Posture:

- Lying:_________________________________________________________________
- Sitting:________________________________________________________________
- Standing:_______________________________________________________________
Gait:

Step Length:_____________________________________________________________
Stride Length:____________________________________________________________
Base width:______________________________________________________________
Cadence:________________________________________________________________
Biomechanical Deviations:__________________________________________________

Hand Functions:
- Reaching:_______________________________________________________________
- Grasping:_______________________________________________________________
- Releasing:_______________________________________________________________
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Assistive Devices:
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III.

Systems Review:

INTEGUMENTARY SYSTEM:
Skin Color _________________________ Skin Texture _________________________
Scar Formation _____________________ Skin Integrity _________________________
Pressure Sores: ________________________________________________________________

RESPIRATORY SYSTEM:
Dyspnea

Yes/No

Onset of Cough _______________

Change in Cough _____________________

Sputum

Yes/No ______________________

Hemoptysis

Yes/No

Stridor

Yes/No

Wheezing

Clubbing of Nails (Shamroths Sign)

Yes/No

Yes/No

Pattern of breathing:____________________________________________________________
Chest wall/Thoracic spine deformity:______________________________________________

CARDIOVASCULAR SYSTEM:

Dyspnea

Yes/No

Orthopnea

Yes/No

Palpitations

Yes/No

Pain/Sweats

Yes/No

Syncope

Yes/No

Peripheral Edema

Yes/No

Cough

Yes/No

Deep Vein Thrombosis:

Resting/Exertional (Mild/Moderate/Severe)

Yes/No

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MUSCULOSKELETAL SYSTEM:
Contractures: __________________________________________________________
Subluxations:__________________________________________________________
Joint mobility: _________________________________________________________
Other pathology: _______________________________________________________
BLADDER & BOWEL FUNCTIONS:
Incontinence: ___________________________________________________________
GASTROINTESTINAL SYSTEM:
Difficulty with Swallowing

Yes/No

Heartburn/Indigestion

Yes/No

Change in appetite

Yes/No

Change in bowel function

Yes/No

AUTONOMIC SYSTEM
Vasomotor: ________________________________________________________________
Trophic Changes: ___________________________________________________________
Postural Hypotension: _______________________________________________________
Reflex Sympathetic Dystrophy: _______________________________________________

IV.

Functional Assessment: (The Functional Independence Measure)

Evaluation 1: Self-care

Item 1. Food
Item 2. Care of appearance
Item 3. Hygiene
Item 4. Dressing upper body
Item 5. Dressing lower body

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Evaluation 2: Sphincter control

- Item 6. Control of bladder

- Item 7. Control of bowel movements

Yes/No
Yes/No

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Evaluation 3: Mobility

- Item 8. Bed, chair, wheel chair

- Item 9. To go to the toilets
- Item 10. Bath-tub, shower

Yes/No
Yes/No
Yes/No

Evaluation 4: Locomotion

- Item 11. Go, wheel chair

- Item 12. Staircases

Yes/No
Yes/No

Evaluation 5: Communication

- Item 13. Auditive comprehension

- Item 14. Verbal expression

Yes/No
Yes/No

Evaluation 6: Social adjustment/cooperation

- Item 15. Capacity to interact and to socially communicate

- Item 16. Resolution of the problems
- Item 17. Memory

Yes/No
Yes/No
Yes/No

Investigation Findings:
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Problem List:
S#

Impairment

Functional Limitation

Functional Diagnosis:
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Diagnostic Tests and Imaging: Labs:

Blood CP
Yes/No
S. Electrolyte
Yes/No
Urine RE
Yes/No
S. Calcium
Yes/No
RFTs
Yes/No
S. Urea
Yes/No
LFTs
Yes/No
S. Creatinine
Yes/No
TFTs
Yes/No
S. Amilase
Yes/No
BSR
Yes/No
S. Cholesterol
Yes/No
BSF
Yes/No
BT.CT
Yes/No
Cardiac Enzyme
Yes/No
Prothrombin time
Yes/No
HCV
Yes/No
HIV
Yes/No
ECG
Yes/No
Imaging:
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Consultations:
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V.

Management

Goals

- Short term: _________________________________________________________________

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- Long term: _________________________________________________________________

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Treatment:
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