INITIAL EVALUATION Personal Data Patients Name: Age: ___ yo Sex: / Address: Status: Married/Single/Divorced Handedness: / (L) Occupation:

on: Religion: RC / Protestant:_________ Nationality: Filipino/Alien Date of Admission: Referring MD: Date of Referral: Rehab MD: Date of IE: Dx: Informant: Px/Relative:______ S: c/c: Px c/o HPI: Personal/Social Hx: (__) coffee drinker: ___ cups/day (__) alcohol beverage drinker: ___ bottles, etc./day (__) cigarette smoker: ___ sticks/day, ____yrs Fxnl Hx: Px used to live an active/sedentary lifestyle

PMHx: (__) previous hospitalization 2o

FHx: Arthritis HPN DM Cancer ___ Asthma ___ Heart disease Paternal ___ ___ ___ ___ ___ ___ ___ Maternal ___ ___ ___

Home Situation: The Px lives in a ___ -storey house c _______________________________________________ Bedroom is @ floor; __ step stairs c __ handrail going up. Bed maindoor: ~ ____ steps; bath: kitchen: sala: Pxs Goal: The Px wants to ______________________

O: OI: endomorphic ambulatory s assistive device (__) open wound (size:____________________; location:__________________) (__) deformity (location: _______________) (__) burn wound (size: ________________; location: __________________) (__) contracture (location: _________________) (__) postural deviation (__) gait deviation (__) atrophy (__) fixation a: BP: ______ mmHg, auscultatory, (L)/ brachial artery, sitting/supine/standing PR: ___ bpm, palpatory, (L)/ radial artery, sitting/supine/standing RR: ___ cpm, diaphragmatic/thoracic breather, sitting/supine/standing T: ____C, (L) / axillary During: BP: ______ mmHg, auscultatory, (L)/ brachial artery, sitting/supine/standing PR: ___ bpm, palpatory, (L)/ radial artery, sitting/supine/standing RR: ___ cpm, diaphragmatic/thoracic breather, sitting/supine/standing T: ____C, (L) / axillary p: BP: ______ mmHg, auscultatory, (L)/ brachial artery, sitting/supine/standing PR: ___ bpm, palpatory, (L)/ radial artery, sitting/supine/standing RR: ___ cpm, diaphragmatic/thoracic breather, sitting/supine/standing T: ____C, (L) / axillary Pain: rating of __/10 during movement/ @ rest Provocation/Palliation Quality Region&radiation

Severity Timing Palpation: normothermic on all exposed body parts (__) nodule (__) edema (__) spasm Neurologic Assessment: Mental Status: alert, conscious, coherent, oriented as to person, place, time, & situation or ____________________________________________________________ ____________________________________________________________ ____________ Sensory Assessment: _______________ on (B) UE & LE as to pain, light touch, & deep pressure (STDs: tip of neurologic hammer = pain; brush = light touch; thumb = deep pressure) Sig: _____________________ MTA: hypertonic/normotonic/hypotonic in (B) UE & LE Muscle tone grade: Ashworth spasticity grade: Sig:______________ DTR: (R) (L)

V/S:

++ ++ ++ ++ ++ ++ ++

++ ++

Legend: 0 areflexia + -- hyporeflexia ++ -- normoreflexia +++ -- hyperreflexia ++++ -- clonus

++

Sig: ___________________________

Pathologic Reflexes: ( ) Babinski ( ) clonus

Special Test:

ROM All major joints of B UE & LE are grossly assessed WNL, actively & passively done, N endfeel, pain-free except: ACTIVE L R GH flex Ext Abd Add IR ER Elbow flex Ext FA sup pron Wrist flex Ext Rad dev Ulnar dev 1st CMC abd Flex Ext Opp 1st MCP flex 1st IP flex MCP flex II PASSIVE L R N 0-180 0-60 0-180 0-70 0-90 0-150 0 0-80 0-80 0-80 0-70 0-20 0-30 0-70 0-15 0-20 0-50 0-80 0-90 Diff EF

III IV V MCP ext II III IV V MCP abd PIP flex II III IV V PIP ext I II III IV V DIP flex I II III IV V DIP ext I II III IV V Hip flex Ext Abd Add ER IR Knee flex Ext Ankle PF DF Inv Ev

0-45

0-20 0-100

0-90

0-10

0-120 0-30 0-45 0-30 0-45 0-45 0-135 135-10 0-50 0-20 0-35 0-15

Subtalar inv Ev T tarsal inv ev 1st MTP flex Ext 1st IP flex MTP flex II III IV V MTP ext I II III IV V PIP flex I II III IV V PIP ext I II III IV V DIP flex I II III IV V DIP ext I II III IV V Cerv flex

0-5 0-5 0-20 0-10 0-45 0-70 0-90 0-40

Ext R lat flex L lat flex R rot L rot TL flex Ext R lat flex L lat flex R rot L rot TMJ dep protrusion retrusion Sig: ( ) LOM

0-40

0-45 0-45 0-45 0-60 0-60 0-80 (4in) 20-30 0-35 0-35 0-45 0-45 3 fing, 2 kn.

0-35

MMT: All mm of (B) UE & LE are grossly graded 5/5 except:

0-60

0 Sig: ( ) strength/weakness on

0-45

MBM UE Ref. pt: Inches above Inches below LE Ref. pt: Inches above Inches below Sig: ( ) atrophy LLM R TLL ALL cm cm Sig: ( ) LLD LGM UE Ref. pt: 2 above 4 above 6 above 8 above Ref. pt: 2below 4 below 6 below 8 below LE Ref. pt: 2 above 4 above 6 above R cm cm cm cm R cm cm cm cm L cm cm cm cm L cm cm cm cm Diff Diff L cm cm Difference R cm cm L cm cm Diff R cm cm L cm cm Diff

8 above Ref. pt: 2 below 4 below 6 below 8 below Balance/Tolerance B= T=

cm R cm cm cm cm

cm L cm cm cm cm Diff

Legend: Balance 0 = cannot assume posn 1 = can assume 2 = can assume, cant maintain 3 = assume, maintain, wt shift 4 = assume, maintain, wt shift, challenge Tolerance Poor (-) <15secs Poor (+) 15-30secs Fair (-) 30-45secs Fair (+) 45-60secs Good >60secs Postural analysis Anterior Head Shoulders ASIS Hips Knees Ankles

Posterior

Lateral

Gait analysis Stance R Diff HS FF MS HO TO L

R cm cm cm

L cm cm cm

Swing R IS MS TS

Sig: ( ) gait deviation ADL Analysis A D E P T Legend: 7 complete indep 6 modified indep 5 supervision 4 minimal assist 3 mod 2 max 1 total assist PT Mx: Px was seen & treated c the ff PT mx: