General Information:

/S/:
C/C:
HPI:
Past Medical Hx:

Condition Date Hospital

Family Medical Hx:

Condition Maternal Paternal Patient

Functional Hx:

Patient Profile:
Personal Hx:
Psychological and Psychiatric Hx:
` FDA:
Lifestyle:
Diet:
Substance Abuse:
Social Hx:
Family Situation:
Home Situation:
Vocational Hx:
Education and Training:
Work Hx:
Finances:

Ancillary Procedures:

Procedure Taken (When & Where) Results

Medications:
Medication (mode as necessary) Dosage/Frequency Indication

Goal:
/O/:
OI:

V/S:

a tx During tx p tx
BP(mmHg)
PR(bpm)
RR(cpm
T (⁰C)
Sig:
Palpation: (may include diagrams)

Neurological Evaluation: (if pertinent)

Mental Status Examination:
Arousal:
Orientation:
Attention:
a. Selective Attention: (digit span test)
b. Sustained Attention:
c. Alternating Attention:
d. Divided Attention: (walki-talkie test)
Cognition:
a. Information and Vocabulary:
 Word Comprehension:
 Naming:
 Repetition:
 Reading:
 Writing:
b. Fund of Knowledge:
c. Calculation ability:
d. Proverb interpretation:
e. Constructional ability:
Memory:
a. Long-term:
b. Short-term:
Sensory Examination:
Superficial:
Light Touch
Area Tested L R

Pinprick
Area Tested L R
 Deep:
Propioception
Joint Tested L R

Kinesthesia
Joint Tested L R

Cortical:
L R
UE LE UE LE
Graphesthesia
Stereognosis

Cranial Nerve Testing:

Cranial nerve Test Findings

Tone Assessment: (refer to sullivan)

Muscle groups Grade

Reflex Assessment:
DTR:
Superficial Cutaneous Reflex:
Primitive/Tonic Reflexes: (refer to sullivan for grading)
Coordination Assessment:
Non-equilibrium Test:
Coordination Test R L Comments

Equilibrium Test:
Coordination Test R L Comments

Overall Neurological Assessment:

Musculoskeletal Assessment:
Anthropometric Assessment: (if pertinent)
MBT: Landmark:
Area Tested L R Difference

Sig:
LGM: Landmark:
Area Tested L R Difference

Sig:
 LLD:
a. True
L R Difference

b. Apparent
L R Difference

c. Segmental
Area L R Difference

Sig:
ROM:
All major joints of the body are actively et passively assessed and found to be WNL,
pain-free and c N end-feel, Except:
Joint AROME PROM N ormal Difference End-feel
motion AROM PROM

Sig:
Accessory Joint Motions Assessment: (refer to sullivan for grading)
Joint Motion Grade

Sig:
MMT/FMT:
All major mm groups of (B) UE, LE, and Trunk are tested and graded 5/5, Except:
Muscle Groups Grade
R L

Grip Strength:
L R Difference

Sig:
Special Tests:
Test Patient’s Response Results

Sig:
Postural Analysis:
Anterior Posterior Lateral

Sig:
Gait Analysis:
Sig:
Pulmonary Assessment: (if pertinent)
a. Breathing Pattern:
Rest Activity
Rate:
Regularity:
Location of ventilation:

b. Cough:
c. Tracheal Deviation:
d. Chest wall Excursion:
Measurement Symmetry
Angle of Louis
Xiphoid process
Between Xiphoid process et
umbilicus

e. Fremitus
Apical
Anterior
Lateral
Posterior

f. Auscultation:
g. CV endurance: 6-MWT
Other tests:

Vestibular Assessment:
Integumentary Assessment:

BADL/IADL/Work/Sport and Recreational Assessment: (Based on Magee)

Activity Performance
Bed mobility
Moving in bed
Sitting up
Hygiene activities
Bathing
Combing hair
Eating activities
Using utensils
Managing glass and
cup
Dressing activities
Putting on clothes
Putting on socks and
shoes
Transfer activities
Bed to chair
Getting into car
Walking activities
Level surfaces
Unlevel surfaces
Sig:

/A/:
PT Diagnosis:
PT Impression:
Problem list: (prioritization)
1. ADL’s
2. Pertinent existing problems (specific)
3. Etc

LTG: ADL’s
STG: (Based on problem lists; SMART)
/P/: