Jashore University of Science and Technology

Dept. Physiotherapy & Rehabilitation

Physiotherapy Assessment Form (Paediatric)

Patients Name: Age: Sex: M/F Date of Birth:

Parents name:
Address:
Doctor/ Consultant:…………………………........Contact no……………………………………………..............
Referred by:……………………………………....Date of referral:………………………………………..............
Referring Diagnosis:……………………………....................Physiotherapist:………………………………………
Date of assessment:

Subjective
Family History: Cousin marriage...............................Blood Group: Father:……………Mother ………..
Mother's health: ………………. …………….…….Father's health:……………………………………
Literacy/ Education:………………………………Literacy/ Education………………………………..
Employment:………………………………………Employment……………………………………….
Siblings: Number................................ Age……………………….Disabilities:
History of the present condition: (Parents perception of the problem and expectation)
………………………………………………………………………………………………………………………...
……………………………………………………………………………...................................................................
Milestones: Rolling……………………Sitting................. Standing........................Walking...............................
Birth history: Premature…………......……Term................................... Post-mature.................................................
During Pregnancy:
Anaemia………………………………..HTN..…………………………..Other illness............................................

During birth:
Delivery…………………………………………..Attended by.................................................................................
At hospital/Clinic/Home…………………………………………………………………………………….............
Prolong labour………………………………………Birth injury.............................................................................
Short labour………………………………………. ............Birth asphyxia ………………………………………
Sudden birth………………………………………...Minutes until baby cried……………………………............
Birth Weight..……………………………………….Others....................................................................................
After birth:
Jaundice………………………………………….............Length of stay in hospital……………………………..
Dehydration ……………………………………….........Treatment received…………………………………….
Seizures …………………………………………............Medication……………………………………………..
Hydrocephalus……………………………………..........UV Light……………………………………………….
Others……………………………………………...........Oxygen…………………………………………………
Investigation:…………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
…………………………………………………………………………………….......................................................
Medical treatment: medicine only/surgery/others…………………………………………………………................
Drug History: Any present meds: Name:……………………………………………………………………..............
Therapy treatments: When:…………………………………………Where:………………………………..............
How long……………………………………………………………………………………………………...............

Previous Medical history:

Epilepsy:………………………………………… Cardiac condition:.............................................................
First seizure……………………………………… Fracture:...........................................................................
Last seizure………………………………………. Respiratory Condition:......................................................
Medication……………………………………… Continence:...................................................................................
Others:..........................................................................................................................................................................

Vision
Fixing.................................... Tracking: ………………Horizontal…………………..Vertical……………………..
Nystagmus:
Squint…………………………………. Glasses........................................
Eyes towards midline L, R
Hearing:
Communication:
Speech/ Vocalization:
Comprehension:
Cognitive &Behavioural Problems:
Home equipment (Seating, braces, splint, shoes, AFO)
 Objective

General Observations: (position, attachments, deformity, drooling, head circumference, main mode of mobility)

Muscle Tone: (decreased increased, min/mod/max, fluctuating, present at rest/ with movt, predominant posture,
rt/lt)
Upper Limbs:
Lower Limbs:
Trunk:

Passive range of motion(WNL--within normal limit, ERT=-end range tightness or measured degrees with
goniometry if any limitation)
HIP Rt Lt Shoulder Rt Lt

Flexion Flexion
Extension Abduction

Abd/Add Rotation

Rotation Elbow

Knee Flexion/extension

Flexion/Extension Sup/porn

Ankle Wrist
DF/PF Flexion/Extension
Inv/Ever Deviation
Toes Finger
Spine ROM:
Muscle strength:
Gross Motor Skills:
Rolling:
Support in prone (wedge):
Bridging:
Lying to sitting:
Sitting: (Preferred position) Floor.

Box:
4 point kneeling:
Crawling:
High kneeling:
Sit to stand
Standing:
Walking: (Gait pattern):
Single leg stance:
Jumping:
Running:
Hopping:
Balance & Co-ordination:

Selective movement:
Fine Motor Function
Grasp:
Release:
Hands to midline:
Hand crossing line:
Hand eye coordination:
Finger isolation:
Pinch grip:
Lt or Rt Dominant:
Activity of Daily Living:
Dressing:
Toileting:
Feeding: Play:
Overall Impression:

Problem list:

Treatment plan:

Signature