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    CP Assessment Format (DDRC)

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    maitri
    This document contains information from a cerebral palsy assessment, including the patient's name, age, address, birth history, medical history, observations from examination of motor skills, sensation, hand function, oromotor abilities, and outcome measures. The assessment documents chief complaints, dominance, prenatal and birth details, cardiovascular status, jaundice history, hernias or heart conditions, examinations of muscle tone, reflexes, range of motion, coordination, and fall history. Diagnoses and short- and long-term treatment goals are also included.

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    CP Assessment Format (DDRC)

    Uploaded by

    maitri
    10 views5 pages
    This document contains information from a cerebral palsy assessment, including the patient's name, age, address, birth history, medical history, observations from examination of motor skills, sensation, hand function, oromotor abilities, and outcome measures. The assessment documents chief complaints, dominance, prenatal and birth details, cardiovascular status, jaundice history, hernias or heart conditions, examinations of muscle tone, reflexes, range of motion, coordination, and fall history. Diagnoses and short- and long-term treatment goals are also included.

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    CP Assessment Format(DDRC)-converted

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    This document contains information from a cerebral palsy assessment, including the patient's name, age, address, birth history, medical history, observations from examination of motor skills, sensation, hand function, oromotor abilities, and outcome measures. The assessment documents chief complaints, dominance, prenatal and birth details, cardiovascular status, jaundice history, hernias or heart conditions, examinations of muscle tone, reflexes, range of motion, coordination, and fall history. Diagnoses and short- and long-term treatment goals are also included.

    Copyright:

    © All Rights Reserved
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    10 views5 pages

    CP Assessment Format (DDRC)

    Uploaded by

    maitri
    This document contains information from a cerebral palsy assessment, including the patient's name, age, address, birth history, medical history, observations from examination of motor skills, sensation, hand function, oromotor abilities, and outcome measures. The assessment documents chief complaints, dominance, prenatal and birth details, cardiovascular status, jaundice history, hernias or heart conditions, examinations of muscle tone, reflexes, range of motion, coordination, and fall history. Diagnoses and short- and long-term treatment goals are also included.

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    of 5

    CEREBRAL PALSY ASSESSMENT

    NAME :
    AGE/GENDER:
    ADDRESS :
    BLOOD GROUP:
    MOTHER`S NAME/AGE :
    FATHER`S NAME/AGE :
    DATE OF BIRTH :
    CHIEF COMPLAIN :
    DOMINANCE : 1) RIGHT
    2)LEFT
    3)MIXED
    4) NOT ESTABLISHED

    HISTORY
    1) BIRTH HISTORY :
    • PRENATAL : (32 TO 42 WEEKS )
    : VACCINATION
    : MORNING SICKNESS
    : MEDICATION
    : HYPERTENSION / DIABETES
    : INFECTION
    : WEIGHT GAIN
    : ABNORMAL VAGINAL DISCHARGE
    : ABNORMAL PAIN SENSATION
    • PERINATAL : (20 WEEKS OF GESTATION TO 7 DAYS OF LIFE)
    : HOW LABOUR PAIN STARTED ?
    : WHAT WAS PRESENTATION OF CHILD?
    (BREECH OR VERTEX)
    • POST NATAL : RECENT COUGH – COLD
    : HEAD INJURY
    : CHILD IN ICU
    : EPILEPTIC ATTACK

    • CARDIOPULMONARY STATUS:
    • PHYSIOLOGICAL JAUNDICE:
    2) MEDICAL HISTORY :
    • CONGENITAL HERNIA
    • CONGENITAL HERAT DISEASE

    3) SURGICAL HISTORY

    4) EDUCATIONAL HISTORY

    5) SOCIO-ECONOMICAL HISTORY

    ON OBSERVATION
    • BODY BUILT
    • ATTITUDE OF LIMB
    • MUSCLE TONE
    • SWELLING
    • INVOLUNTORY MOVEMENT
    • GAIT
    • POSTURE
    • EXTERNAL APPLIANCE
    • SKIN CHANGES
    • DROOLING OF SALIVA

    ON PALPATION:
    • TENDERNESS
    • WARMTH
    • BONY ABNORMALITY / DEFORMITY
    • OEDEMA
    ON EXAMINATION:
    1) MOTOR EXAMINATION:

    ➢ GROSS MOTOR EXAMINATION


    1) MILESTONE ACHIEVED
    2) MODE OF TRANSITION : PRONE PIVOTING (ON ABDOMEN)
    : CREEPING
    : CRAWLING
    : BUTTOCK SHIFTING
    : BUNNY HOPPING
    3) LIMB LENGTH
    4) MUSCLE GIRTH
    5) MUSCLE TONE
    6) REFLEXES : (PRIMITIVE REFLEXES)
    7) TIGHTNESS / DEFORMITY
    8) NECK MOVEMENT :
    ▪ STATIC MOVEMENT: GOOD / FAIR / POOR
    ▪ LATERAL MOVEMENT : GOOD / FAIR / POOR
    ▪ VERTICAL MOVEMENT : GOOD/ FAIR / POOR

    9) TRUNK/SPINE MOVEMENT :
    o FLEXION / EXTENSION : GOOD / FAIR / POOR
    o LATERAL FLEXION : GOOD / FAIR / POOR
    o ROTATION : GOOD / FAIR / POOR
    10) RANGE OF MOTION

    ➢ FINE MOTOR EXAMINATION


    • PREHENSION GRIP :
    o REACH : GOOD / FAIR / POOR
    o GRASP : GOOD / FAIR / POOR
    o PLACEMENT : GOOD / FAIR / POOR
    o RELEASE : GOOD / FAIR / POOR
    • PRICISION GRIP :
    • LATERAL : GOOD / FAIR / POOR
    • SPHERICAL : GOOD / FAIR / POOR
    • CYLINDERICAL : GOOD / FAIR / POOR
    • HOOK : GOOD / FAIR / POOR
    2) SENSORY EXAMINATION
    SUPERFICIAL : TOUCH
    : PAIN
    : TEMPERATURE
    : PRESSURE
    DEEP : PROPRIOCEPTION
    : VIBRATION
    : KINESTHESIA

    3) HAND FUNCTION EXAMINATION


    COORDINATION :
    HAND TO MOUTH : GOOD / FAIR / POOR
    BILATERAL HAND : GOOD / FAIR / POOR
    MIDLINE COORDINATION : GOOD / FAIR / POOR

    4) FALL EXAMINATION
    FREQUENCY OF FALL
    DIRECTION OF FALL

    5) OROMOTOR EXAMINATION
    ARTICULATION
    SPEECH
    OUTCOME MEASURES:

    PAEDIATRIC ASSESSMENT SCALE


    GROSS MOTOR FUNCTIONAL CLASSIFICATION SCALE
    GROSS MOTOR FUNCTION MEASURE (GMFM)

    DIAGNOSIS :

    SHORT TERM GOALS :

    LONG TERM GOALS:

    PLAN FOR TREATMENT:

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