Taral Patel
Name:
DOB:
Age:
Sex: M/F, Cis/ Trans
Medical Diagnosis:
Referring Physician:
Date:
PT Dx:
History of Current Problem:
What brings you in? ________________________ Date of Onset: ________________________
MOI: How long? _______________________________________________________________
Pain
Current: ____/ 10
At best: ____/ 10
At worst: ____/ 10
How would you describe your pain? (Circle all that apply)
Sharp Dull Burning Aching Tingling Numb Constant Radiating
Location (circle):
What aggravates it? ____________________________________
____________________________________________________
What relieves it? ______________________________________
____________________________________________________
Does it get worse at night? Yes/ No
Social/ Home History
Single _______ Married _______
Occupation: ________________ Limitations: Y/N
Physical Activities: _____________________________________________________________
Hobbies: ______________________________________________________________________
Use of Tobacco/ Drugs/ Alcohol:
Living Condition (Circle): Home/ Apt.
Stairs: Y/ N
Rails: Yes/ No
Difficulties with any transfers: Toilet: Y/ N Shower: Y/ N Bed: Y/ N Chair: Y/N Car: Y/N
Any difficulties inside home? Y/N please explain:
Assistive Devices/ Durable Medical Equipment:
Indoor: _______________________________________________________________________
Outdoor: ______________________________________________________________________
Long distance: _________________________________________________________________
Medical History
Do you take any prescription medications? Yes/ No If yes:
Medication (with Dosage & Frequency)
Do you have any allergies? Yes/ No If yes: ___________________________________________
Do you take any nonprescription medications or supplements? Yes/ No If yes: ______________
______________________________________________________________________________
Have you ever had surgery? Yes/ No
What/Where: __________________________________
Date: ______/ 20_____
What/Where: __________________________________
Date: ______/ 20_____
What/Where: __________________________________
Date: ______/ 20_____
Within the past year have you had any of the following medical tests? Date: ________________
MRI
Blood test
Bone scan
CT scan
Doppler ultrasound
EKG
Xray
Other: ________________________________________________________________________
Falls? Yes/ No (Recent/Previous)
Date:
Environment & Frequency: ____________________________________________
___________________________________________________________________
___________________________________________________________________
Signature: _______________________________
Date: ___________________________
Taral Patel
Hospitalization: Yes/ No
Reason of stay: _________________________________________
Vision/ Hearing correction? Yes/ No
Mental Examination: ☐ Spontaneously opens eyes ☐ Converse appropriately ☐ Follows verbal requests
Oriented to Person (self, others) ☐ Oriented to place (state, town, building)
☐ Oriented to time (day, time, month, year) ☐ Native language:
☐ Other:
Other Medical Complications:
☐
Past Medical History (Check all that apply): ☐ NONE of the below
☐ Heart attack (MI)
☐ Angina
☐ Congestive Heart Failure
☐ Mitral Valve Prolapse
☐ High Blood Pressure
☐ High Cholesterol/ triglycerides
☐ Heart disease
☐ Arrhythmia
☐ Anemia
☐ Stroke
☐ Bleeding disorder
☐ Blood clots in lung (PE)
☐ Blood clots in extremities (DVT)
☐ Peripheral vascular disease
☐ Peripheral neuropathy
☐ Cancer, Type:
☐ Immunologic: change in skin, sleep problems
☐ Endocrine: change in weight, hot flashes
☐ Hepatic/ Biliary: change in taste or smell
☐ Psychology: rashes or recent skin changes
☐ Pulmonary: shortness of breath, cough up blood
☐ Cancer: loss of appetite or unexpected weight loss
☐ Gynecologic: bleeding or menstrual cycle pain
☐ Psychological: depressed, mood & memory Δ
Graphesthesia
Sterognosis
Barognosis
Muscle Groups
MMT*
ROM
Tone**
* MMT is typically:
0: absent
1: trace, flicker
1+: < 50% ROM gravity min
2-: gravity min > 50%
2: gravity min no resistance
2+: gravity min w/ resist. Or agst
grav <50% ROM
3-: agst grav 100%-50% ROM
3: no resist, full ROM, agst grav
3+: with resistance give quick
4: with resistance little give
5: with max resistance
** Tone is according to
Modified Ashworth Scale
0: No incr in tone
1: Slight incr, catch and
release at end range
1+: Slight incr, catch with min
resistance < ½ ROM
2: Incr ms tone thru ROM
3: Incr ms tone affecting
passive ROM
4: Incr ms tone affect active
ROM
L
R
L
R
L
Signature: _______________________________
R
Date: ___________________________
Taral Patel
Shoulder elevation
Shoulder flexion
Shoulder ABD
Shoulder IR
Shoulder ER
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Finger flexion
Finger extension
Hip flexion
Hip extensors
Hip ABD
Hip ADD
Hip IR
Hip ER
Knee flexion
Knee extension
DF
PF
Coordination Assessment:
Skill: non-Equilibrium
Finger to nose
Heel to shin
Skill: Equilibrium
Seconds
Tandem gait
Rhomberg test
SOT/ mCTSIB
Reciprocal Mvmts
Symmetry
Speed
Fatigue?
Upper Extremities
Lower Extremities
Motor Assessment
Left
Right
Tremors
Present
Absent
Present
Absent
Involuntary/ Uncontrolled mvmt Present
Absent
Present
Absent
Muscle atrophy
Present
Absent
Present
Absent
Width
of
base
Score
FIM Scale
1. Transfers
No Helper
L 7 Complete Independence (Timely &
a. Bed, Chair, Wheelchair
Safely)
E
b. Toilet
V 6 Modified Independence (Devices)
c. Tub, Shower
2.
Locomotion
E Modified dependence
Helper
a. Walk
L 5 Supervision (Pt= 100%)
b. Wheelchair
4 Minimal Assist (Pt= 75%)
3 Moderate Assist (Pt= 50%)
Complete dependence
2 Maximal Assist (Pt =25%)
1 Total Assist (Pt <25%)
3.
c. Stairs
Social/Cognition
a. Memory
b. Problem Solving
Signature: _______________________________
Date: ___________________________
Taral Patel
Cranial Nerve Integrity
Upright Motor Scale: R/L
(Intact, Impaired, Absent) (Left, Right)
CN I
Hip Flexion
W M S
Hip Extension W M S
CN II
CN III
Knee Flexion
W M S
Knee
Extension
W M S E UT
CN IV
CN V
Dorsiflex
W S
Plantarflex
W M S E UT
CN VI
CN VII
* For UMC:
W = weak
CN VIII
M = moderate
CN IX
S = strong
CN X
E = excessive
CN XI
UT = unable to test
CN XII
Reflex Integrity
Deep Tendon Reflexes (0, 1+, 2+, 3+, 4+, C= Clonus with __ B for beats, R= Right/ L= Left)
Jaw (CN V)
Biceps/ Musculocutaneous n (C5,C6)
Brachioradialis/ Radial n. (C5,C6)
Triceps/ Radial n. (C6, C7)
Finger flexors/ Median n. (C6-T1)
Hamstrings/ Tibial branch of Sciatic
n. (L5, S1, S2))
Quadriceps/ Femoral n. (L2, L3, L4)
Achilles/ Tibial n. (S1-S2)
Superficial Cutaneous Reflexes
Plantar (S1, S2)
Abdominal Reflex: (T10)
Below umbilicus
Above umbilicus
Primitive & Tonic Reflexes
Flexor withdrawal
Crossed Extension
Traction
Moro
Startle
Grasp
ATNR
STNR
Positive supporting
Associated reactions
Postural Analysis
Sitting:
Standing:
Other:
Activity-Based Task Analysis
Weight Shift:
Mid-phase:
Initial Lift:
Final position:
Signature: _______________________________