Clinical Rotation IV form (UIPT)

Neurological Disorder Assessment Form

1) Name: 2) Age: 3) Gender:

4) Date of admission: _ 5) Occupation

6) Marital Status: 7) In-Patient/ Out-Patient

8) Diagnosis: 9) 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

PastMedical/SurgicalHistory
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
• Ambulation
Normal/In parallel bar/with or without pelvis
Standing
harness/walker/cane/
Walk In parallel bar/with or without pelvis harness/walker/cane
• Weight.bearing/weight.shifting
Sitting
Standing
• Hand Function (Fine Motor)
Reaching
Grasping
Releasing
• Self-Help skills
Self Feeding Dependant / Independent
Dressing/Undressiing Dependant / Independent
Transitions Dependant / Independent
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).
RFT Cerebral Angiography/Vertebral Angiogram/Carotid
Angiogram
LFT Spinal tap/lumbar puncture
Lipid profile Evoked potentials.
BSF,BSR Myelogram.
Hep B, Anti HCV Neurosonography
EEG Ultrasound/sonography
EMG Magnetic Resonance Angiogram (MRA)/Magnetic
Resonance Venogram (MRV)
MRI Biopsy
X-ray Others
CT scan
NCS

Plan Of Care:
Body structure and function:

Activity Level:

Participation Level:

Supervised by:
Dr. Samia Sarmad, PT
Incharge Pediatric Physical Therapy &
Rehabilitation Center
ULTH- Lahore