Clinical Rotation at ULTH

Neurological Disorder Assessment Form

Demographic Data:
1) Name: ________________________________ 2) Age:_________ 3)Gender:_________

4) Date of Birth: ___________________________ 5) Occupation_______________________

6) Marital Status: __________________________ 7) Ward:____________________________

8) Admission Date: ________________________ 5) Blood Group:______________________

10) Diagnosis: _______________________________________________________________________

11) Referred by: _______________________________

Subjective History
Presenting complaints/Chief Complaints:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

History of Present Illness:

Duration_____________________________________________________________________________

Onset_______________________________________________________________________________

Severity (i) Mild (ii) Moderate (iii) severe

Type (i) Motor (ii) Sensory (iii) Both

Systems Review

General_____________________________________________________________________________

Cardiovascular System________________________________________________________________

Respiratory System___________________________________________________________________

Alimentary System____________________________________________________________________
Urinary System_______________________________________________________________________

Nervous System_______________________________________________________________________

Integumentary System_________________________________________________________________

Endocrine System_____________________________________________________________________

Genitourinary System_________________________________________________________________

Gynecological System_________________________________________________________________

Past Medical/Surgical History:

Any other similar disease________________________________________________________________

Others_______________________________________________________________________________

Occupational History_______________________________________________________________

Personal & Social History:

● Sleep (normal less or more)
● Apatite(normal less or more)
● Micturition (normal less or more ,burning dysuria)
● Bowl habits(normal , constipation or diarrhea )
● Smoking or other addiction (smoking , drinking or drug abuser),None
● Education____________________________________________________________

General Health Status:

a) Excellent b) Good c) Fair d) Poor

Drug History:
● Past Medicine Used____________________________________________________

● Current Medicine Used_________________________________________________

Family History:
● Heart disease ● Cancer

● Hypertension ● Psychological

● Stroke ● Arthritis

● Diabetes ● Osteoporosis
 ● Others ● None

Objective History & Assessment

🞛ON OBSERVATION

Attitude of limbs

Posture

Gait

Pattern of Movement

Mode of Ventilation

Edema

Muscle Wasting

Pressure Sores

Deformity

Wounds

External/Appliances/
Assistive Devices

🞛ON PALPATION

Warmth
⬜ Yes ⬜ No
Swelling
⬜ Yes ⬜ No
Tenderness
⬜ Yes ⬜ No
Tone
⬜ Yes ⬜ No
🞛 ON EXAMINATION

⮚ Higher Mental Function

Level of Consciousness
Level of Orientation
Speech
Verbal responses
Motor responses
Eye opening
Memory/Cognition
Communication
Attention
Involuntary Movements
(Mention if yes)
🞛SENSORY SYSTEM
● Superficial
Pain
Temperature
Touch
Pressure
● Deep
Movt. Sense (Kinesthetic
Sensation)
Pos. Sense (Proprioception)

Vibration
⮚Check Co-Ordination
● Non-Equilibrium Tests
Finger to nose
Finger opposition
Pronation/Supination
Rebound test
Tapping (hand/foot)
Heel on shin
Drawling a circle (hand/foot)
Pointing and past pointing
● Equilibrium Tests

Normal Posture / Normal Posture with vision occluded/ Feet

Standing
Together / on one foot / lateral trunk

Walk Sideways / Backward / in a circle / on heels/ on toes

● Balance
Sitting
Standing
Balance reactions
● Posture
Lying
Sitting
 Standing
● Hand Function
Reaching
Grasping
Releasing
🞛Reflexes
Planter (UMND/Babinski
Response)
Ankle
Knee Jerk
Brachioradialis
Triceps
Biceps
🞛Motor System
(Voluntary Control/Strength/Tone)
Upper Limb (Rt./Lt)
Lower Limb (Rt./Lt)

Investigations

CBC Positron emission tomography (PET). 

Cerebral Angiography/Vertebral Angiogram/Carotid
Angiogram
Spinal tap/lumbar puncture
profile Evoked potentials. 
SR Myelogram. 
, Anti HCV Neurosonography
Ultrasound/sonography
Magnetic Resonance Angiogram (MRA)/Magnetic
Resonance Venogram (MRV)
Biopsy
Others
an
NCS

Plan Of Care:
Supervised by:
Dr. Waqar Afzal Dr M. Asim Arif Dr. Husna Haroon
Incharge Physical Assistant Prof Senior Lecturer
therapy and UIPT-UOL UIPT-UOL
Rehabilitation, ULTH