NAME:

DATE OF BIRTH:
SEX:
FATHERS NAME:
MOTHERS NAME:
ADDRESS:
TELEPHONE NO.:
HEAD CIRCUMFERANCE (at birth time):
CHEST CIRCUMFERANCE (at birth time):
WEIGHT (at birth time):
APGAR SCORE:
CHIEF COMPLAINT:

DATE OF ADMISSION:

HISTORY:
PRESENT:
RISK FACTOR
PRENATAL:
MATERNAL AGE
ATTEMPTED ABORTION
BLEEDING DURING LATE PREGNANCY
TRAUMA OR ACCIDENTS
EXPOSURE TO RADIATIONS
Rh. INCOMPATIBILITY
MALNUTRITION
HYPERTENTION
JAUNDICE
DIABETES
EXCESSIVE FOETAL MOVEMENT
SLUGGISH FOETAL MOVEMENT
INFECTIONS (VENEREAL)
SMOKING / ALCHOHOLISM
USE OF DRUG / MEDICATIONS
CONVULSIONS
ASTHAMA
LUNG DISEASES
ECLAMPSIA
FEVER WITH RASHES IN I TRIMESTER

NATAL AND NEONATAL:

HOME DELIVERY
PREMATURE
POSTMATURE
INDUCED LABOUR
PROLONGED LABOUR
PRECEPITATE LABOUR
BREECH PRESENTATION
CAESERIAN DELIVERY
SUCTION DELIVERY
PROLAPSED CORD
CORD AROUND NECK
LOW BIRTH WEIGHT (<2500gms)
HIGH BIRTH WEIGHT (>4000gms)

DELAYED BIRTH CRY

ABNORMAL COLOUR
RESPIRATORY DISORDER
APNOEA
BIRTH ASPHYXIA
LOW APGAR SCORE (0-3 in 5 min)
JAUNDICE AT BIRTH
SEPTICAEMIA
MECONIUM ASPIRATION
MICROCEPHALY
HYDROCEPHALUS
CONGENITAL ABNORMALITY
INTRAUTERINE GROWTH RETARDATION
NEONATAL CONVULSIONS
FEEDING PROBLEMS
DECREASED AMNIOTIC FLUID
AMNIOTIC FLUID LOSS

POST NATAL
MENINGITIS
ENCEPHALITIS
MEASLES
JAUNDICE
CONVULSIONS
MALNUTRITION
TRAUMA / ACCIDENT
HAEMORRHAGE
GENERAL DEVELOPMENTAL DELAYS / MILESTONES
EYE CONTACT
SOCIAL SMILE
HEAD CONTROL
SIDE TURNING
SITTING
ROLLING
CRAWLING
STANDING
WALKING
ASSOCIATED DISORDER
GENERAL UNDERSTANDING
COMMUNICATION
VISION
HEARING
ORIENTATION
BEHAVIOUR

FAMILY:
CONSANGUINITY
EPILEPSY
DISABILITY
FAMILY CHART
PATERNAL AGE:

MATERNAL AGE:

PREVIOUS ABORTION
MISCARRIAGE
STILL BIRTH
NUMBER OF CHILDREN

NUTRITIONAL HISTORY:
MEDICAL HISTORY:
PHYSIOTHERAPY HISTORY:

ON OBSERVATION
GENERAL
BUILT
FACIAL EXPRESSION
ASYMMETRY / DEFORMITY
CONGENITAL DEFORMITY
CYANOSIS
CLUBBING
COLOUR
ODEMA

GROSS MOTER FUNCTION:

SUPINE
SYMMETERY OF POSTURE
U.L
L.L
HEAD TUERNING TO SIDES
PRONE
PROTECTIVE HEAD TURNING
HEAD RISING
COMING TO SUPINE FROM PRONE
SPINAL CURVATURE AND ANY DEFORMITY
SITTING
WITH SUPPORT
WITHOUT SUPPORT
STANDINGWITH ORTHOSIS
YES / NO
WITHOUT ORTHOSIS (MAIANTAIN)
TRUNK STABILITYMAINTAINED OR NOT
WALKINGWITH SUPPORT
WITHOUT SUPPORT
GAIT
RESPIRATORY PATTERN

LOCAL:
HYPERTROPHY
MS.WASTING
FASICULATION

ATROPHY
SCAR / INCISION
BREATHING PATTERN:
THORACOABDOMINAL
ABDOMINOTHORACIC
NEUROLOGICAL GRAFTS
DRAINS
VENTILLATORS
FLUID INTAKE / OUTPUT
INTUBATION:
MONITORS
INTUBATORS
RYLES TUBE
CATHETERS

ON PALPATION
WARMTH
SWELLING
TENDERNESS
TEXTURE OF SKIN
TIGHTNESS / CONTRACTURE / DEFORMITY
SCAR:
ADHESIVE
NON ADHESIVE
TONE:
HYPOTONIC
ISOTONIC
HYPERTONIC

ON EXAMINATION:
HIGHER CORTICAL FUNCTION:
ALERTNESS
RECOGNISES FAMILY MEMBERS AND STRANGERS
FOLLOWS ALL COMMANDS OR NOT
IS ABLE TO TELL ALL NEEDS OR NOT
GIVES RESPONSE TO ALL OR NOT
IS WELL AWARE OF SURROUNDINGS OR NOT
WELL ORIENTED OR NOT

CRANIAL NERVE EXAMINATION:

II, III, IV, VI
OPTICAL BLINK REFLEX
SHINE LIGHT IN OPEN EYE: RAPID CLOSURE OF THE EYEEYES FOLLOWS MOVEMNT
V
ROOTING AND SUCKING REFLEX
CLENCHING OF TEETH
VII
FACIAL SYMMETRY WHILE SMILING OR CRYING
WRINKLING FOREHEAD
NASOLABIAL FOLD
VIII

IX, X

XII

LOUD NOISES YEILDS MOROS REFLEX UNTIL 4 MNTHS

ACOUSTIC BLINK REFLEX
EYES FOLLOWS DIRECTION OF SOUND
SWALLOWING
GAG REFLEX
COORDINATED SUCKING
COORDINATED SWALLOWING
SYMMETRY OF TONGUE

SUPERFICIAL SENSATION:
TOUCH
TEMP
PRESSURE

DEEP SENSATION
VIBRATION
2 POINT DISCRIMINATION
PROPRIOCEPTION

CORTICAL SENSATION
GRAPHESTHESIA
STEREOGNOSIS

DEVELOPMENTAL REFLEXES:
PRIMITIVE / SPINAL REFLEXES:
ROOTING
SUCKING
LANDAU
PARACHUTE
FLEXOR WITHDRAWL
CROSSED EXTENSION
TRACTION
MORO
STARTLE
GRASP:
PLANTAR
PALMAR
TONIC / BRAINSTEM REFLEXES:
ATNR
STNR
STLR
POSITIVE SUPPORTING
ASSOCIATED REACTION
MIDBRAIN / CORTICAL REFLEXE:
NOB
BOB
LR
BOH
OR
PROTECTIVE EXTENSION
EQUILIBRIVM REACTION

PRIMARY REACTION
INVOLUNTARY FUNCTION

DEEP TENDON REFLEXES:

UPPER LIMB:
BICEPS
TRICEPS
BRACHIORADIALIS
LOWER LIMB:
QUADRICEPS
HAMSTRING
TENDO ACHILLIS

SUPERFICIAL TENDON REFLEXES:

ABDOMINAL:
DIMINISHED
NORMAL
EXAGGERATED
PLANTAR / BABINISKIS SIGN:
CORNEAL:

MOTOR EXAMINATION
TONE:
HYPOTONIC
HYPERTONIC
(ASSESSMENT ACCORDING TO MODIFIED ASHWORTH SCALE / MMT)
RIGHT
LEFT
SHOULDER:
FLEXORS
EXTENSORS
ABDUCTORS
ADDUCTORS
EXTERNAL ROTATORS
INTERNAL ROTATORS
ELBOW:
FLEXORS
EXTENSORS
SUPINATOR
PRONATOR
WRIST:
FLEXORS
EXTENSORS
ULNAR DEVIATORS
RADIAL DEVIATORS
FINGERS:
(LATERAL 4 FINGERS)
FLEXORS
EXTENSORS
ABDUCTORS
ADDUCTORS
(THUMB)
FLEXORS
EXTENSORS
ABDUCTORS

ADDUCTORS
OPPONENS
HIP:
FLEXORS
EXTENSORS
ABDUCTORS
ADDUCTORS
EXTERNAL ROTATORS
INTERNAL ROTATORS
KNEE:
FLEXORS
EXTENSORS
ANKLE :
PLANTARFLEXORS
DORSIFLEXORS
INVERTORS
EVERTORS
TOES:
FLEXORS
EXTENSORS
ABDUCTORS
ADDUCTORS

JOINT RANGE OF MOTION:

RIGHT
SHOULDER:
FLEXION
EXTENSION
ABDUCT ION
ADDUCTION
EXTERNAL ROTATION
INTERNAL ROTATION
ELBOW:
FLEXION
EXTENION
SUPINATION
PRONA
WRIST:
FLEXION
EXTENSION
ULNAR DEVIAT ION
RADIAL DEVIATION
FINGERS:
(LATERAL 4 FINGERS)
FLEXION
EXTENSION
ABDUCT ION
ADDUCTION
(THUMB)
FLEXION
EXTENSION
ABDUCTION

LEFT

ADDUCTION
OPPONENS
HIP:
FLEXION
EXTENSION
ABDUCTION
ADDUCTION
EXTERNAL ROTATION
INTERNAL ROTATION
KNEE:
FLEXION
EXTENSION
ANKLE :
PLANTARFLEXION
DORSIFLEXION
INVERTION
EVERSION
TOES:
FLEXION
EXTENSION
ABDUCTION
ADDUCTION

MUSCLE GIRTH:
UPPER LIMB:
DELTOID
BICEPS
TRICEPS
BRACHIORADIALIS
LOWER LIMB:
QUADRICEPS
HAMSTRING
CALF

LIMB LENGTH MEASURMENT

RIGHT
APPARENT:
TRUE
COMPLETE
SEGMENTAL:
FEMUR
TIBIA

POPLITEAL ANGLE
ADDUCTOR ANGLE

RESPIRATORY ASSESSMENT
CHEST EXPANSION
AUSCULTATION
CHEST SYMMETRY

LEFT

BOWEL & BLADDER:

UNINHIBITED
ATONIC
AUTONOMOUS
MOTOR
SENSORY

ORAL FUNCTION:
PALATE
HIGH OR LOW
SWALLOWING

SCALES:
GROSS MOTOR: GMFM
FINE MOTOR: ERAHALT DEVELOPMENTAL
INFANIB

FUNCTIONAL EVALUATION:

wee FIM / FIM / PEDI

COORDINATION & BALANCE: PBS

SITTING
FINGER TO NOSE
FINGER TO FINGER
HEEL TO SHIN
ALTERNATE SUPINATION-PRONATION
STANDING
RHOMBERG SIGN
TENDOM WALKING
SIDE WALKING
STEP CLIMBING &DESCENDING

INVESTIGALIONS
X-RAY:
C.T SCAN
MRI
ELECTRODIAGNOSTIC TESTS:

COMMENTS:
PROVISIONAL DIAGNOSIS:
TREATMENT PLAN: