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Name: ________________________ Attending Physician: ______________
Age: __________________________ Referring Doctor: ________________
Sex: __________________________ Physiatrist: _____________________
Address: _______________________ Date of Referral: _________________
Civil Status: ____________________ Date Admitted: __________________
Handedness: ___________________ Date of Consultation: _____________
Occupation: ____________________ Date of IE: _____________________
Religion: _______________________ Informant/Reliability: _____________
Nationality: _____________________ Diagnosis: _____________________
Type of Patient: _________________ Chief Complaint: ________________
Attending Unit: __________________

ONSET: acute/insidious
LOCATION: localized/radiating (upto where?)/referred
QUALITY/CHARACTER: sharp/burning/dull/gnawing
PROGRESSION: gradually/rapidly progressive
INTENSITY: mild/mod/severe
FREQUENCY: intermittent (4 hrs)/occasional (4-8 hrs)/frequent (8-12 hrs)/constant (12-16 hrs))
VARIABILITY: changes quality of pain in a day
DURATION: how long?
MIGRATION PATTERNS: transfer from one place to another
AGGRAVATING & RELIEVING FACTORS: effects of posture, activity/exertion, rest heat/cold, walking, work/home
EFFECT ON ADL, SLEEP, WORK, SOCIAL, RECREATIONAL: interrupt sleep/ work efficiency/inability to perform ADL

Premorbid Status: Patient is __dependent in all aspects of ADL as to self-care (eating, grooming, bathing, UE/LE
dressings, toileting), mobility, transfers, locomotion, communication, and social cognition with __ min/mod/max

____ months PTIE

What were the first symptoms and signs experienced observed by the patient?
When did the problems occur? (The onset should be as exact as possible)
How long did these symptoms and signs last (duration)?
Were there known precipitating factors to the symptoms and signs? If yes, mention these factors.
Were there known aggravating factors? If yes, mention them.
What factors relieve the patient of the symptoms and signs? How long does this relief last (transient, relief
of ___ min or hours, indefinite or permanent relief?)
What did the patient do about the problem?
a. Did he seek consult?
i. If yes, with whom? Where? What was the recommendation and subsequent outcome of
the consult?
ii. If not, why?
b. Did he do something to relieve himself of the problem?
i. If yes, what did he do and what was the result?
What followed after the onset of the initial problem?
c. Was there deterioration, total relief, unchanged/static, recurrences?
d. Were there additional symptoms and signs noted?
i. If yes, describe each

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e. When did each of these additional problems occur in relation to the initial symptom?
f. What did the patient do regarding these new problems or change in clinical course?
What effect did these problems have on the patient? (Did these affect patients strength, mobility,
ambulation, and ADL?)
Has the patient undergone PT previously?
g. If yes, what was the treatment given?
i. How long was PT done?
ii. Why was therapy terminated?
iii. What was the effect of therapy?
iv. What home instructions were given?
v. What home instructions were followed?
What is the attitude of the patient and immediate family to the illness?
What are the expectations of the patient and immediate family regarding the medical/surgical,
rehabilitation and PT treatment?
What other symptoms and signs are often associated with this illness and major problems? (Present or

Patient is __dependent in all aspects of ADL as to self-care (eating, grooming, bathing, UE/LE dressings, toileting),
mobility, transfers, locomotion, communication, and social cognition with __ min/mod/max assistance.

(Skin HPI)
Changes in skin: dryness, pruritus, sores, rashes, lumps, color, texture, odor, amount of perspiration, changes in
wart/mole, lesion that does not heal or is chronically irritated
Temporal sequence: date of initial onset, time sequence of occurrence and development, sudden or gradual onset,
date of recurrence
Symptoms: itching, pain, exudates, bleeding, color changes, seasonal or climate variations
Location: skin folds, extensors/flexor surface, localized, generalized
Associated symptoms: presence of systemic disease or high fever, relationship to stress or leisure activities
Recent exposure to drugs, environmental or occupational toxins, or chemicals to persons with similar skin condition
Apparent cause, patients perception of cause
Travel history: where, when, length of stay, exposure to diseases, contact with travellers
What the patient has been doing for the problem, response to treatment, what makes the condition worse or
How the patient is adjusting to the problem
Medications: topical or systemic, non/prescription

- Cardiopulmonary problems
- HPN (un/controlled, highest/baseline BP, when? Meds? Why? How? Where?)
- DM (un/controlled, when? Meds? Why? How? Where?)
- Hospitalizations
- Accidents/Trauma
- Allergies
- Hypersensitivity
- Ca
- GI problems
- Genito-urinary problems
- Nutritional problems
- Neuromuscular problems
- Other medical illnesses
- Medications (name, dosage, frequency, prescribed, for what)

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(Skin PMHx)
- Previous skin problems: sensitivities, allergic skin reactions, allergic skin disorders, lesion, treatment
- Tolerance to sunlight
- Cardiac, respiratory, liver, endocrine, systemic diseases

- Smoker (___pack/year)
- Alcoholic beverage drinker (___bottle/session/years) if previous, when stopped _______
- Educational background
- Type A/B personality
- Prefers to eat_______________________
- Daily activities/hobbies/sedentary lifestyle
- Nature of work (hours, position when working)
- Lives with
- Type of house
- Plight of stairs
- Bedroom is located on ____ floor
- Bedroom is ____ steps away from CR
- Living arrangements
- Patient has sleep disturbances
- Prefers to sleep in ____ mattress in ____ position
- Happily married
- Knowledgeable about the condition
- Financially supported
- Expectation/goal
- Motivated
General survey
- Bedridden/fast/bound
- Ambulatory with/out assistive device/assist (__man assist)
- Alert/lethargic/stupor/coma, in/coherent, un/cooperative
- Ecto/endo/mesomorph/Aesthenic
- Not/in apparent pain and respiratory distress
- Attachments
- Preferred position of extremities/typical arm posture
- Postural deviation (see PA)
- Gait deviation (see GA)
- Facial asymmetry
- Aphasia
- Synergy patterns

Vital signs
a during p
BP (mmHg)
PR (bpm)
RR (cpm)
Int: All VS are WNL
Sig: For baseline purposes


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- Normo/hypo/hyperthermic
- Normal/fair/poor senile skin turgor, mobility and consistency
- Dry, scaly skin
- Trophic skin changes
- Edema
- Scars
- Skin lesion
- Nail status
- Skin complexion: overall complexion / paleness / cyanotic / jaundiced, icteric / abnormal pigmentations /
flushed / erythematous
- Texture and moisture: smoothness, roughness, scaly/atrophic, elastic / dehyrdrated, edematous/ oil,
greasy, excessively sweaty
- Temperature: cool/warm, hot
- Turgor: normal, good/fair/poor
- Consistency: firmness, flabbiness, softness / fluctuant, infiltrated, indurated
- Mobility: fold of skin easily moved or rolled / adherent
- Presence of skin lesions:
o Quality (color, size, border (in/distinct margination) / surface characteristics (dry, greasy, moist,
purulent, bleeding, verrucous))
o Location or distribution of lesions (scattered & generalized/annular (ring)/clustered
(groups)/confluent or coalescent (multiple lesions blending together)/linear (streaks))
o configuration of lesions
o shape (flat/oval/irregular)

lesion type
o arrangement of the lesions (grouped/single/symmetrical/randomized)
o effect of pressure (blanch)
o palpatory findings (tender/adherent/fixated to underlying tissue)

- Slurred speech
- Dysarthria
- Dysphagia
- Lip color
- Color of conjuctive and sclera, size of pupils, reaction to light, eyelid
- Head: size, shape, scalp scar and lesions, facial asymmetry/facial expressions/distinct facies
- Eyes: closure of eyelids, color of conjuctiva & sclerae, size of pupil, position & movement of eyeball,
abnormal eye movement or protrusion, cataract
- Ear: Appearance of external ear/discharge
- Nose: external nose, discharge, flaring
- Lip: color
- Tongue: color & movement
- Swallowing ability, mastication, odor of breath
- Neck: movement & position
- Facial muscles and actions (see facial muscle testing) bells palsy

Head and scalp symmetry, tenderness (over areas of frontal and maxillary sinuses), swelling, depression, scalp
Hair texture, color and distribution
External ear and periauricular area tenderness or laceration
Temporal arteries thickening, hardness, tenderness

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Face deformity, crepitus, tenderness and lacerations, nasal bone for crepitus or deviation; frontal and maxillary
sinuses for swelling; maxilla for tenderness and deformity; entire length of the mandible
Neck tracheal position (pathologic condition in the chest), movement of hyoid bone, thyroid and cricoid cartilages
with swallowing
Thyroid gland size, shape, configuration, consistency, tenderness, nodules (should be small, smooth and free of
nodules; rise freely with swallowing)

- SCM prominence
- Jugular vein distention
- Use of accessory muscles for respiration
- Tracheal position (pathologic condition in the chest), movement of hyoid bone, thyroid and cricoid
cartilages with swallowing

- ab/N) HR and rhythm
- (ab/N) heart sound
Chest and Lungs
- Regular/irreg/asymmetrical/apical
- Secretion
- Cough and sputum
o strong/weak/in effective/non productive
o Color: red/rust/purple/yellow green/pink/flecked
o Odor: foul smelling/sweet smelling
o Texture: thin/watery/frothy/gritt/thick/mucus/layered
o Amount/Quantity: ____mL or cupful/day
- Bruises/lesions/scars
- Prominence or use of accessory muscles of respiration (SCM, scalene, trapz)/Nasal flaring/lip
pursing/cynanosis/nails for clubbing and cyanosis*
- Fremitus
- Chest deformity: Barrel/Pigeon/Funnel
- Rib cage contour: retraction/widened intercostals spaces
- Chest symmetry: lag/splinting
- Breathing pattern: diaphragmatic/thoracic; rate and depth: rapid/shallow, slow/deep breathing
- Type of breathing: tachy(>20cpm)/brady (<12cpm)/hypernea (N)
- Auscultation: / breathe/voice sounds; adventitious sound
- Palpation: tenderness/subcutaneous emphysema/lumps or masses/pleural friction rub// tactile
fremitus/mediastinal or tracheal shift/respiratory excursion or chest expansion/fremitus
- Percussion: ab/N diaphragmatic exercusion N = 3.5 cm; resonant/hyperresonant/dull; tymphanic/flat

- Rounded/protuberant
- Tenderness
- Surgical incision
- Abnormal sounds
- Muscle spasm
- Beevors test

Back and Spine

- Tenderness
- Pressure sores

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- Trigger points
- Taut bands/nodules
- Muscle spasm
- Spine curvature
- Spine deformities
- Edema
- Cervical spine: Head & neck posture (head in midline, military posture)/Shoulders level/Muscle spasm
or any asymmetry (atrophy of deltoid, torticollis)/Facial expression/Bony & soft tissue contours (cervical
spine)/ Evidence of ischemia in either upper limb (color, ulceration, or vein distention
- Thoracic spine: kyphosis/scoliosis/breathing/chest deformities
- Lumbar spine: fauns beard (tuft of hair)/cafe au lait spots/neurofibromatosis

- Pressure sores
- Edema
- Swelling
- Atrophy (MBM)
- Peripheral cyanosis
- Preferred position
- Deformities
- Color
- Moisture

ROM: All joints of (B) UE and LE are WNL, actively and passively done, pain-free c (N) end-feels,
(R) (L)
Motions (N) (R) (L) End-Feel
TMJ depression 35-50 mm Firm
TMJ anterior protrusion 3-10 mm Firm
TMJ posterior protrusion
TMJ lateral deviation 6-15 mm Firm
Cervical flexion 45 Firm
Cervical extension 45 Firm
Cervical rotation 60 Firm
Cervical lateral flexion 45 Firm
Thoracic flexion 45 Firm
Thoracic extension 45 Firm
Thoracic rotation 40 Firm
Thoracic lateral flexion 50 Firm
Lumbar flexion 60 Firm
Lumbar extension 35 Firm
Lumbar rotation 30 Firm
Lumbar lateral flexion 18 Firm
Thoraco-lumbar flexion 80 Firm
Thoraco-lumbar extension 25 Firm
Thoraco-lumbar rotation 35 Firm
Thoraco-lumbar flexion 45 Firm
Shoulder flexion 180 Firm
Shoulder abduction 180 Firm
Shoulder adduction 0 Firm

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Shoulder IR 70 Firm
Shoulder ER 90 Firm
Elbow flexion 150 Soft
Elbow extension 0 Hard
Elbow supination 80 Firm/Hard
Elbow pronation 80 Firm
Wrist flexion 80 Firm
Wrist extension 70 Firm
Radial deviation 20 Hard
Ulnar deviation 30 Firm
Finger MCP flexion 90 Hard
Finger MCP extension 45 Firm
Finger MCP abduction 20 Firm
Finger PIP flexion 100 Hard
Finger PIP extension 0 Firm
Finger DIP flexion 70 Firm
Finger DIP extensions 0 Firm
Thumb CMC abduction 70 Firm
Thumb CMC flexion 15 Soft
Thumb CMC extension 20 Firm
Thumb opposition Soft
Thumb MCP flexion 50 Hard
Thumb MCP extension 0 Firm
Thumb IP flexion 80 Firm
Thumb IP extension 20 Firm
Hip flexion 120 Soft
Hip extension 20 Firm
Hip abduction 45 Firm
Hip adduction 30 Firm
Hip IR 45 Firm
Hip ER 45 Firm
Knee flexion 135 Soft
Knee extension 10 Firm
Ankle DF 20 Firm
Ankle PF 50 Firm
Ankle inversion 35 Firm
Ankle eversion 15 Hard
Great toe/1st MTP flexion 45 Firm
Great toe/1st MTP extension 70 Firm
Great toe/1st PIP flexion 90 Soft
Lesser toes MTP flexion 40 Firm
Lesser toes MTP extension 40 Firm
Lesser toes PIP flexion 35 Soft
Lesser toes DIP flexion 30 Firm
Lesser toes DIP extension 60 Firm
Int: (+) LOM towards
Sig: 2 to tightness, contractures, denervation, pain

Schobers Test
(R) (L) Diff (N)

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Trunk >10 cm
Trunk / >5 cm
Int: (+) LOM towards trunk
Sig: 2 to pain, hams tightness

Modified Schobers Test

(10 cm above S1 and 5 cm below S1)
(R) (L) Diff (N)
Trunk >10 cm
Trunk / >5 cm
Int: (+) LOM towards trunk
Sig: 2 to pain, hams tightness

MMT: All mm of neck, trunk, (B) UE and LE are graded 5/5, except:
Muscles (R) (L) Muscles (R) (L)
TMJ depressors Finger MCP extensors
TMJ anterior protrusors Finger MCP abductors
TMJ posterior protrusors Finger PIP flexors
TMJ lateral deviators Finger PIP extensors
Cervical flexors Finger DIP flexors
Cervical extensors Finger DIP extensors
Cervical rotators Thumb CMC abductors
Cervical lateral flexors Thumb CMC flexors
Thoracic flexors Thumb CMC extensors
Thoracic extensors Thumb oppositors
Thoracic rotators Thumb MCP flexors
Thoracic lateral flexors Thumb MCP extensors
Lumbar flexors Thumb IP flexors
Lumbar extensors Thumb IP extensors
Lumbar rotators Hip flexors
Lumbar lateral flexors Hip extensors
Thoraco-lumbar flexors Hip abductors
Thoraco-lumbar extensors Hip adductors
Thoraco-lumbar rotators Hip IRors
Thoraco-lumbar flexors Hip ERors
Shoulder flexors Knee flexors
Shoulder abductors Knee extensors
Shoulder adductors Ankle DFors
Shoulder IRors Ankle PFors
Shoulder ERors Ankle invertors
Elbow flexors Ankle evertors
Elbow extensors Great toe/1st MTP flexors
Elbow supinators Great toe/1st MTP extensors
Elbow pronators Great toe/1st PIP flexors
Wrist flexors Lesser toes MTP flexors
Wrist extensors Lesser toes MTP extensors
Radial deviators Lesser toes PIP flexors
Ulnar deviators Lesser toes DIP flexors
Finger MCP flexors Lesser toes DIP extensors

Int: (+) mm weakness of

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Sig: 1-2/5 2 to disuse, atrophy, denervation, pain
3-4/5 2 to mm activity

Reps Grade
0 1 No ability
1-4 2 Partially labored
5-9 3 Reliable ability but abnormal movement
10-15 4 Reliable normal to near normal

Reps Grade
5 4
4 3
3-2 2
1 1

- Raise toes
- Raise heel
- Flex phalanges
- Inversion and eversion

Facial Muscle Testing (F/WF/NF)

Orbicularis oculi (R) (L)

Levator palpebrae superioris
Corrugators supercilii

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Zygomaticus major
Levator anguli oris
Orbicularis oris
Depressor anguli oris
** Zygomaticus Minor/levator labii superioris

Painful Arc Diagram

Pain: - mild (1-3)
= moderate (4-6)
-= severe (7-10)

LOM: 1 0-25%
2 26-50%
3 51-75%
4 76-100%

Int: __% LOM towards _________ with PS ___

Special Test
Findings: (+/-)______ sign/test
Int: patient was/nt able to do...../pain/click
Sig: (+/-) condition

Grip Strength Measurement

(Using: Sphygmomanometer pumped at __mmHg)
(R) (L)
Trial 1
Trial 2
Trial 3
Sig: 2 to weakness, pain
Anthropometric Measurement
Landmark: Medial Tibial Plateau (MTP)

(R) (L) Dif

__ above
__ above
__ above
__ below
__ below
__ below
Int: (+) hyper/atrophy of
Sig: 2 to condn, mm activity/weakness

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Landmarks (R) (L) Diff (2-3 cm)
___ inches proximal/distal to ____
Int: (+) hyper/atrophy of
Sig: 2 to condn, mm activity/weakness

Landmarks Maximal Inspiration Resting Expiration Diff
Level of Axilla (T2)
Angle of Louis
Xiphoid Process
10th Rib
Int: (+) CEM
Sig: 2 to

Leg Length Measurement

Segmental Leg Length
(R) (L) Diff
Umbilicus ASIS
ASIS Medial condyle
Medial condyle medial/lateral malleolus
Int: (+) LLD

Apparent Leg Length

Reference (R) (L) Diff
Umbilicus to medial/lateral malleolus
Int: (+) LLD

True Leg Length

Reference (R) (L) Diff
ASIS to medial/lateral malleolus
Int: (+) LLD
Mental Status
I. Appearance and Behavior
a. Grooming
i. Hygiene
ii. Concern with appearance
iii. Appropriateness of dress for season, gender and occasion
b. Emotional status
i. Carelessness, indifference, inability to sense emotions in others, loss of sympathetic
reactions, unsual docility, rage reactions, excessive irritability
c. Body language
i. Posture
ii. Eye contact during conversation
iii. Excessively energetic movements
II. Level of Consciousness
a. Glasgow coma scale for TBI patients (<8 severe brain injury; 9-12 moderate; 13-15 minor)

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Eye Opening Best Motor Response Verbal Response
Spontaneous 4 Follow motor commands 6 Oriented 5
To speech 3 Localizes 5 Confused conversation 4
To pain 2 Withdraws 4 Inappropriate words 3
No response - 1 Abnormal flexion 3 Incomprehensible sounds 2
Extensor response 2 No response 1
No response 1
b. Level of consciousness (alert, lethargy, obtunded, stupor, coma)
c. Orientation
III. Cognitive function
a. Memory
i. Immediate recall
ii. Recent memory (short-term)
iii. Remote memory (long-term)
b. Attention
i. Sustained
ii. Divided
iii. Focused
c. Emotional response/behaviors
i. Affect, mood: irritability, agitation, depression, withdrawal
ii. Safety, judgment: impulsivity and lack of inhibition
iii. Self-centeredness (egocentricity)
iv. Frustration tolerance
v. Insight into disability
vi. Ability to follow rules of social conduct
vii. Ability to tolerate criticism
d. Higher level of cognitive abilities
i. Judgment/problem solving
ii. Abstract reasoning
iii. Fund of general knowledge (learn new things/generalize learning to new situations)
iv. Calculation
v. Sequencing
IV. Speech and language
a. Expressive function
i. Fluency, speech production (articulation/coherence: circumlocution, echolalia,
preservation, neologism)
b. Receptive function
i. Comprehension
c. Non-verbal communication
i. Read and write (agraphia)
ii. Gestures, symbols, pictographs

Patient is oriented to time, place, and person. Reasoning and arithmetic calculation abilities intact.
Immediate, recent, and remote memory intact. Appropriate mood and feelings expressed. Speech clearly and
smoothly enunciated. Comprehends directions.

Consciousness Arousal
- Fully awake; responds appropriately to varying stimuli
- Oriented to person; some confusion with orientation to place and time
- Can become agitated with minimal stimulation, especially when tired

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- Demonstrates difficulty with concentration and attention
- Able to follow simple instructions (1- or 2-level command) but occasionally fogets what is asked of her
- Easily forgets what she is doing

Motor Evaluation
Muscle Tone
Grade Name
0 Atonia No tone
1 Hypotonia Minimal tone (mabilis bumaba)
2 Normotonia (N)
3 Hypertonia Excessive tone (matagal bumaba)
4 Severe hypertonia

Modified Ashworth Grading Scale (Spasticity)

0 No in muscle tone
1 Check and release at the end of the ROM
1+ Catch throughout the remainder (< half of the ROM)
2 Marked in muscle tone
3 Passive movement is difficult
4 Rigid

GMT (Stroke): All muscles are grossly graded 3-5/5, except:

(supine) Finger Elbow /
Head Finger / Knee /
Trunk Finger abd Scapular retraction
Shoulder Finger add
Shoulder / Thumb (sitting)
Horizontal abd Thumb / Shoulder depression
Horizontal add Hip Shoulder elevation
Shoulder abd Hip / Hip ER and ankle inversion
Shoulder add Hip ER Hip IR and ankle eversion
Shoulder ER Hip IR
Shoulder IR Hip abd (standing)
Elbow Hip add Ankle DF 5/5: 10x|4/5: <5|
Elbow / 3/5: 1
Pronation (prone) Ankle PF
Supination Neck / Hip and knee / (squat 5x)
Wrist Trunk /
Wrist / Shoulder /

Int: (+) mm weakness

Sig: 2 mm activity, pain, discomfort, flaccidity

Myotomal Testing (SCI)

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(R) (L)
C5 elbow ors
Int: C6 wrist /ors
C7 elbow ors
Higher cortical function: MMT, FMT, screening test
finger ors
finger abd (interossei)
Individual MMT
L2 hip (iliopsoas)
L3 knee /ors
Specific Muscle Testing L4 ankle DFors (PNI)
L5 big toes /ors (R) (L)
S1 ankle PFors
Radial Nerve
Elbow /ors
Wrist /ors
Median Nerve
Wrist ors
Ulnar Nerve
Finger abductors
Finger adductors
Sciatic Nerve
Knee ors
Tibial Nerve
Ankle PFors
Deep Peroneal Nerve
Ankle DFors
Ankle invertors
Femoral Nerve
Knee /ors
Superficial Peroneal Nerve
Ankle evertors

Sensory Evaluation
CN testing: All CN are intact, except:
I. Smell VII. Facial expressions
II. Sight/Snellen chart VIII. Hearing and balance
III. Eyes motions IX. Swallow, gag reflex
IV. SO4 X. ahhh, gag reflex
V. Sensation XI. SCM, trapz
VI. LR6 XII. Tongue deviation

Dermatome (SCI)
C2 occipital protuberance T2 apex of axilla
C3 supraclavicular fossa T3 3rd intercostals space
C4 top of acromiclavicular joint T4 nipple line
C5 lateral side of antecubital fossa T5 5th
C6 thumb T6 6th
C7 middle finger T7 7th
C8 little finger T8 8th
T1 medial side of antecubital fossa T9 9th

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T10 umbilicus L4 medial malleolus
T11 11th L5 dorsum of the foot at the 3rd MTP joint
T12 inguinal ligament S1 lateral heel
L1 1/3 distance between T12 and L2 S2 popliteal fossa (midline)
L2 midanterior thigh S3 ischial tuberosity
0 absent
L3 medial femoral condyle S4-S5 perineal area
1 impaired
Int: 2 normal

Area of Isolated Supply (PNI)

1. Median nerve: DIP of index finger and middle finger and lateral of ring finger
2. Axillary nerve: lateral aspect of arm
3. Musculocutaneous nerve: lateral aspect of forearm
4. Radial nerve: 1st dorsal web space
5. Ulnar nerve: little finger and medial half of ring
6. Common peroneal nerve: fibular head
7. Superficial peroneal nerve: lower aspect of the lower third of leg
8. Deep peroneal nerve: 1st dorsal web space of the foot
9. Sural nerve: medial lower 3rd aspect of lower leg
10. Anterior cutaneous nerve: mid-anterior thigh
11. Obturator nerve: medial side of thigh
12. Medial plantar nerve/lateral: medial/lateral part of sole
13. Tibial nerve: calcaneal area

Superficial Deep Combined cortical

Pain Propriocetion (up or down) Stereognosis (familiar objects, coins, keys, combs,
Temperature Kinesthesia (doing up or down) etc)
Light touch Vibration 2-point discrimination (= or < 6cm)
* lateral spinothalamic Double simultaneous stimulation
Pressure Barognosis (weight of different sizes)
* anterior spinothalamic Graphesthesia (written on palm)
Recognition of texture (rough, smooth, soft, hard,
2-point discrimination documentation
STD used: aesthesiometer
Findings: 50% partial sensory loss (7-15 cm) on _______
Interpretation: (+) 50% sensory deficit as to 2-pt discrimination on ____ 2 to ____
Higher cortical function: Gross Sensory Testing (superficial, deep, combined)
SCI: Dermatomal (superficial, deep)
PNI: AOIS (superficial)


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Neurological level Most caudal segment with a grade of 5 for motor and 2 for sensory
Complete (absent) or incomplete Presence of sensory or motor function in 24-25
(present) SCI
Zone of partial preservation Most caudal segment with partial innervations (grade 3 for motor and 1
for sensory)

ASIA Impairment Scale

A = complete (-) sensory; (+) motor function
B = incomplete (+) sensory; (-) motor
C = incomplete < 3 (muscle grade)
D = incomplete >/= 3
E = complete Sensory and motor are normal

PNI: Sensory tests are done ff the peripheral distribution of each peripheral nerve:
Findings: (+) ___% sensory loss as to pain, light touch, deep pressure, hot and cold to the __________________
Interpretation: 2 to UMNL

Reflex Testing
1. Jaw reflex (CNV)
0 areflexia
2. Biceps (C5, C6)
+ - hyporeflexia
16 of 23 ++ - normoreflexia
3. Triceps (C7, C8)
4. Brachioradialis (C5, C6)
+++ - hyperreflexia
5. Patellar (L3, L4)
++++ - clonus
6. Achilles Tendon (S1, S2)

Pathologic Reflex
1. Babinski: lateral foot 8. Bechterevs:
2. Chaddocks: lateral ankle/malleolus 9. Glabellar: point glabella Parkinsons
3. Gordons: gastrocnemius Disease
4. Oppenheims: tibialis anterior 10. Snout
5. Gonda: flex 4 lateral toes 11. Stransky: abduct little finger
6. Scheafers: achilles 12. Clonus: UMN sign
7. Hoffmans: flick index finger
Int: (+) pathologic reflex
Sig: 2 to UMNL

Balance and Coordination Testing

I. Dysdiadochokinesa d. Toe to PTs finger
a. Finger to nose IV. Hypotonia
b. Alternate finger to nose a. Passive movement
c. Pronation/supination b. Tendon reflexes
d. Knee flexion/extension V. Resting tremor
e. Walking at varying speeds a. Observation during rest
II. Dysmetria VI. Postural tremor
a. Pointing and past pointing a. Observation during work
b. Drawing a circle or figure 8 b. Alternate nose to finger
c. Heel on shin c. Finger to finger
d. Placing feet on floor markers while d. Finger to PTs finger
walking e. Toe to PTs finger
III. Movement decomposition (dyssynergia) VII. Asthenia
a. Finger to nose a. Fixation or position holding
b. Finget to PTs finger b. MMT
c. Alternate heel to knee

Basal Ganglia
VIII. Rigidity IX. Bradykinesa
a. Passive movement a. Walking, observe arm swing and trunk
b. Observation during work motion
c. Observation during rest b. Walking, after speed and direction
c. Abrupt start/stop
d. Observation during work

Dorsal Column
X. Postural disturbances d. Standing, one foot in front
a. Fixation or position holding e. Standing on one foot
b. Displace balance unexpectedly XI. Gait disturbances
c. Standing, after BOS a. Walk along a straight line

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b. Walk sideways, backwards d. Alter speed in walking
c. March in place e. Walk in circles
(non-equilibrium (10x) equilibrium)

Coordination assessment form
Rating used:
4 normal performance
3 only slight difficulty
2 moderate difficulty
1 severe difficulty
0 unable to accomplish

Balance Testing
Findings: ( ) Rombergs: sway open and close eyes cerebellar; close eyes dorsal column
( ) Tandem Gait

Balance and Tolerance

Balance Tolerance

Balance Tolerance
1 assume Nil cant do
2 maintain Poor 15-30 minutes
3 weight shift Fair 45-60 minutes
4 can be challenged Good - >60 minutes

Int: Pt has ____ in balance and ____ tolerance

Sig: 2 to mm weakness, flaccidity,

Postural Analysis: All bony landmarks of posture are WNA, except:

Done in _________ position:

Anterior View:
Head straight on shoulder
Posture of jaw normal
Tip of nose in line with sternum
Upper traps neck line equal on both sides
Shoulders are level
Clavicle & AC joint level & equal
No protrusion, depression of sternum & ribs
Waist angles are equal
Carrying angles of elbow equal
Palms of both hands face body in a relaxed position
high points of iliac crests are the same height
ASIS are level

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Pubic bones are level at the symphysis pubis
Patella of the knee points straight ahead
Knees are straight
Heads of the fibula are level
Medial & lateral malleoli of ankles are level
Two arches are present in the feet & equal on both sides
Feet angle out equally
No bowing of bone
Bony & soft tissue contours are equally symmetric

Lateral View:
Earlobe in line with tip of shoulder & high point of iliac crest
Each spinal segment has a normal curve
Shoulders are in proper alignment
Chest, abdominal & back muscles have proper tone
No chest deformities
Pelvic angle is normal
Knees are straight, flexed or in recurvatum

Posterior View:
Head in midline
Shoulders level
Spines & inferior angle of scapula level, medial borders equidistant from spine
Spine is straight (plumbline dropped from C7)
Ribs protrude or are symmetric
Waist angles level
Arms equidistant from body and equally rotated
PSIS level
Gluteal folds level
Knee joints level

Achilles tendon descend straight to calcaneus

Heels straight
Bowing of femur or tibia

(forward flexion)
Patient flex forward at hips, arms drop vertical, feet together, knees straight
Anterior/posterior skyline views:
o Asymmetry of rib cage (e.g. rib hump)
o Asymmetry in the spinal musculature
o Presence of pathologic kyphosis
o Lumbar spine straightens or flexes
o Restriction to forward bending (e.g. spondylolisthesis or tight hamstrings)

Patient seated on the stool, feet on the ground, back unsupported
o Anterior view knees same distance from floor
o Side view if knee protrudes farther than the other
o Note whether the spinal curves increase or decrease when patient is seated

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(supine lying)
- Observation:
o Position of head, cervical spine & shoulder
o Chest area for any protrusion or sunken areas
o Abdominal musculature if strong or flabby
o Waist angles if equal
o Extension in the lumbar spine
o Lower limbs descend parallel from the pelvis
(prone lying)
o Position of head, neck & shoulder girdle
o Presence of any condition (e.g. sprengels deformity or rib hump) and spinal deviations
o PSIS are level
o Musculature of buttocks, posterior thighs & calves
Int: (+) postural deviation
Sig: 2 to habituation, scoliosis, condition

Gait Analysis: All parameters of gait are essentially (N), except:

(R) (L)
Hip Knee Ankle Hip Knee Ankle
Stance Phase
//(N) 30 //(N)
HS //(N) extension Neutral //(N) 30 flexion Neutral
flexion extension
//(N) 20 //(N) 20 //(N) 15
FF //(N) 20 flexion //(N) 15 PF //(N) 20 flexion
flexion flexion PF
//(N) 15 //(N) 5
MS 0 //(N) 15 flexion //(N) 5 DF 0
flexion DF
//(N) 10 //(N) 10 //(N) 15
HO 0 //(N) 15 DF 0
extension extension DF
//(N) 20 //(N) 20 //(N) 50 //(N) 20
TO //(N) 50 flexion //(N) 20 PF
extension extension flexion PF
Swing Phase
//(N) 50
Accn Neutral //(N) 50 flexion Neutral Neutral Neutral
//(N) 25 //(N) 65
MS //(N) 65 flexion Neutral //(N) 25 flexion Neutral
flexion flexion
Other Significant Findings:
TRUNK: Lean (B/F), Lateral Lean (R/L), Rotation (R/L)
PELVIS: Hikes, Tilting (A/P), Drop, Lacks forward or backward rotation, lateral pelvic shift
HIP: Flexion (absent, limited or excess), Inadequate extension, Rotation (IR/ER), Add/Abd
KNEE: Flexion (absent, limited or excess), Inadequate extension, Wobbles, Hyperextended, Varum or
ANKLE: Forefoot contact, Foot flat contact, Foot slap, Excess plantar or dorsi, Excess valgus/varus, Drag, No
heel off
TOES: Up, Inadequate extension, Clawed
Width of the walking base
(R) & (L) step length
(R) & (L) stride length
Distance walked (6-minute walk test)
Walking velocity

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Gait deviations
Each joint
Each subphase of gait
Assistive device used
Arm swing
Sig: 2 to mm weakness, condition

A. Self-care __Tub, shower
__Grooming D. Locomotion
__Bathing __Walk, wheelchair
__UE dressing __Stairs
__LE dressing
__Toileting E. Communication
B. Sphincter Control __Expression
__Bladder Management
__Bowel Management F. Social Cognition
__Social expression
C. Mobility, Transfers __Problem solving
__Bed, chair, wheelchair __Memory

7 Complete independence
6 Modified independence (device)
5 Modified dependence (supervision)
4 Modified dependence (minimal assist)
3 Modified dependence (moderate assist)
2 Complete dependence (maximal assist)
1 Complete dependence (total assist)

Int: Pt is __dependent in all aspects of ADL as to self-care, sphincter control, mobility, transfers, locomotion,
communication, and social cognition c total device

__Grooming Legend:
__Toileting 1 No ability
__Ambulation 2 Partial labored, unreliable ability/beginning ability
3 Reliable ability but with grossly abnormal pattern
__Dressing 4 Reliable ability but with normal or near normal
__Bed mobility

Functional Analysis
Functional Activities
(Mobility Activities) - Sitting
- Bed mobility - Standing
- Transitional movements - Ambulation
o Supine to sitting o Ambulation in level surfaces
o Sitting to standing o Stair climbing

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- Transfer activities (Household Activities)
- Wheelchair activities - Cooking
- Cleaning
(ADL) - Lawn work
- Feeding
- Grooming (Community Activities)
- Dressing - Driving
- Bathing - Shopping
- Toileting - Social outings

ADL Analysis
Pt is __dependent in all aspects of ADL as to self-care (eating, grooming, bathing, UE/LE dressings,
toileting), mobility, transfers, locomotion, communication, and social cognition with __ min/mod/max assistance.

PT Impression
MD Dx of __________ further defined by inability to
_________________________________________________ 2 (+) pain, (+) LOM, (+) mm weakness, (+)
hyperreflexive of DTR, (+) postural dev, (+) gait dev

Rehab Potential

For example:
Pt prognosis is good because patients response in PT treatment is good and shows very good motivation
towards the treatment. Strict compliance to the treatment should be done for better improvement.

LTG (Time frame: __ mos)


Example (Stroke):
Therapeutic Goal: For the patient to improve and enhance the cognitive function, communication,
awareness and use of hemiparesis side, motor function, postural control and balance, gait and locomotion, ability
to perform physical actions, tasks, or activities, independence in ADL, tolerance of upright postures and activities,
problem solving and decision-making skills, ability to assume/resume self-care and home management, and be
able to ambulate from total assist to minimal assist.
Preventive Goal: Pts caregiver will demonstrate proper knowledge on pts medical dx, proper adherence
to HEP, and understanding of pts condition to further the pts improvements at home and to prevent occurrence of
2 complications like DVT, pressure sores; decrease joint integrity on (R) UE and LE, and decrease muscle strength
on (L) UE and LE./ and to prevent further regression such as skeletal deformity to improve mobility and
enhance/improve acquisition of new skills.

Problem List STG Proposed PT Mx c Rationale

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Pt will be seen and treated as an OPD pt 2-3x a week c the f PT Mx:
1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________
4. ___________________________________________________________
5. ___________________________________________________________

Done at least ___:
1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________
4. ___________________________________________________________
5. ___________________________________________________________

HIP/Caregiver Education:
1. Postural awareness
2. Proper adherence and compliance to tx
3. Proper knowledge about the condition

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