Pediatric Ph al Therapy Assessment Sheet > Name of The Patient: > Date: » Evaluator’s Name: » Date of Initial Evaluation: > Diagnosis: > Referring Physicia Next visit: » Frequency of physical therapy sessions/ week: > Informal evaluation: o History Taking * Personal history * Nick name: * Birth date: + Age: + Corrected age (if under 2 years): + Sex: + Height: + Weight: + Address: + Telephone number: * Occupation: * History of present illness + Onset: * Course: + Duration: + GMFCS: + Recent medical or surgical interventions that may have resulted in a need for a PT examination: + Current surgical or other precautions: + Medical complication as a result of recent medical intervention: + Current level of function: + Function before intervention and if there has been a recent decline or improvement in activity and participation at home, at school, or within the community: * Past medical history * Birth (obstetric) history: > Prenatal: © Problems during pregnancy:© Drugs taken at the 1* trimester: © Gestational age: 9 Trauma: © Radiation: © Viral infection: © Vascular insufficiency © Oth > Perinatal: © Duration of labor: o Type of labor: o Type of presentation: © Maternal condition: © Complications during delivery (e.g., cyanosis/ hypoxia): © Birth weight: © Instrumented delivery: © Congerital anomalies: © Other: Postnatal: © Complications after delivery (¢.g., jaundice): © Trauma: © Fever: © Infection (e.g., meningitis, encephalitis) 2 Incubatio © Convulsions: © Other: v » Previous disease! fracture: » Previous investigations: + Past medical or surgical procedures: + Previous physiotherapy: + Other rehabilitation service: + Full medication list (including over-the-counter [OTC] and home remedies): + Vaccination history: * Developmental history Patient can do Aativity Patient can't do Head controf Rolling Sitting Creeping ‘Standing L Walking + Time frame for milestone acquisition: Page 2 of 13+ Functional gains or decline: + Use of or need for assistive devices, braces, assistive technology & adaptive equipment: « History of Associated! disorders (Comorbidities) * Vision: + Hearing: + Speech; * Drooling: + Dysphagia: * Cognition: + Behavior: + Respiratory: + Epilepsy: + Other: * Family & Social history + Number of children in family: + Order of child: + Parent consanguinity: * Other affected children (similar cases in the family): + Family support: + Cultural and language consideration: | + Barriers to success (transportation, access, family stressors, financial limitations): | + Home setup: + School setup: + Access to community activities and participation: + Chief Complaint: o Observation General observation: + Rate & pattern of breathing (as in Horner syndrome) * Color of skin * Posture « Persistence of primitive reflexes ‘* Movement (spontaneous motility of child; kicking) « Asymmetry of movement (as in Erb’s palsy & hemiplegia) + Amount of support during carrying * Amount of assistance during walking (none, self, assistive device, or another person) + Upper limb function «Involuntary movements Page 3 of 13,© Initiation of movement (2.g., hemiplegic start movement with sound side) + Isolated joint movement (selective motor control) + Associated movernent + Associated reaction Specific observation: 1, Head: « Size of head (hydrocephalus, microcephalus) «= Position of head (torticollis) 2, Extremities: ‘© Swelling, atrophy, shortening + Deformities * Any scar related to surgery © Etb’s position + Frog leg position * Scissoring pattern * Fisted hand + Disproportion between upper body & lower body (as in spina bifida) 3. Face: + Asymmetry between both sides * Features of Down syndrome 4. Trunk: = Deformities * Surgical operation (scar tissue) « Tuft of hair * Lipoma # Winging of scapula co Palpation > Formal evaluation: © Muscle tone assessment Modified Ashworth Scale (MAS-B) ONo increase in muscle tone. 1 Slight increase in muscle tone, manifested by a catch and release (clasp knife phenomenon) or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension, 1+ Stight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM, 2 Marked increase in muscle tone through most of ROM, but affected part(s) easily moved. 3 Considerable increase in muscle tone, passive movement difficult. 4 Affected part(s) rigid in flexion or extension Page 4 of 13,(MAS-B) Elbow flexors _ Knee extensors Other muscle group * Other methods for assessment of hypotonia: + Postural fixation * Recoil test + Traction response * Shaking * Scarf sign * Heel to ear * Gower sign o Reflexive maturation assessment Spinal level: ni > Flexor withdrawal > Extensor thrust > Crossed extension | > Crossed extension 11 > Crossed extension Il Brainstem level ‘Asymmetrical tonic neck reflex ‘Symmetrical tonic neck reflex Tonic labyrinthine supine Tonic labyrinthine prone Positive supporting reaction Associated reactions vvyy vv Midbrain level: > Neck righting acting on body » Body righting acting on body > Labyrinthine righting > Optical righting > Amphibian reaction Cortical level Equilibrium reaction- supine Equilibrium reaction- prone Equilibrium reaction- quadruped Equilibrium reaction- sitting Equilibrium reaction- kneeling Hopping reaction- side Hopping reaction- forward Hopping reaction- backward Equilibrium reaction- dorsiflexion vryYvvyyYY [Automatic movement reac Page S of 13> Moro reflex > _Protective extensor thrust Deep tendon reflexes: > Biceps > Brachioradialis > Triceps > Quadriceps |__» Gastrocnemius _________| Other reflexes: » Palmar grasp > Rooting > Galant > > Glabellar Ste o Assessment of motor development: « Denver II: Suspect Normal 1 Untestable O *» GMFM: Total score: uw % o Musculoskeletal assessment: * Joint ROM assessment Movement Range Right | Left Upper ti Shoulder: Flexion Extension Abduction ‘Adduction Med. Rotation Lat. Rotation Etbow: Flexion Extension, Radio-uinar: ‘Supination Pronation Wrist: Flexion Extension Page 6 of 13,Radial deviation — Ulnar deviation Hip: Flexion Extension Abduction ‘Adduction Med. Rotation, Lat. Rotation Knee: Flexion Extension Ankle: Dorsitlexion Plantartiexion Subtatar: Eversion Inversion « Muscle flexibility assessment Test Elbow flexors ‘Wrist & finger flexors ‘Subscapularis Shoulder adductors Forearm pronators [Hand fumbricals & interossei “Thomas test ‘Ober test Modified Ober test Hip adductors Passive straight leg raising test, [Ely test Popliteal angle test | Silfverskidid test Sternocleidomastoid Upper trapezius Other: _ Page 7 of 13* Ligamentous laxity assessment = en iene eighton-Horan Ligament Laxity Scale B One point is given for each positive ligament laxity for total of $ points: + Right and left elbow hyperextension >15 degrees (2 points) + Right and left knee hyperextension >15 degrees (2) + Right and left thumb to wrist (2) + Right and left fifth digit hyperextension >90 degrees (2) « Palms touch the floor with fegs straight (1) Pes eee = Muscle strength assessment Muscle aie Right a ‘Upper lim: Shoulder: Flexors Extensors Abductors Adductors ‘Med. Rotators Lat. Rotators Elbow: Flexors Extensors Radiowulnar: Supinators Pronators: Wrist: Flexors Extensors Radial deviators Ulnar deviators Lower lim Hip: Flexors Extensors 4 Page 8 of 13‘Abductors Adductors Med. Rotators Lat. Rotators Knee: Flexors Extensors Ankle: Dorsiflexors: Plantertlexors Subtalar: Evertors Invertors Face: Frontalis Orbicularis Corrugator Nasalis, Procerus Levator anguli oris Levator labii sup. / Zygomaticus minor Resorius ‘Zygomaticus major Depressor labil inf, / Platyema Orbiculatis oris Buccinator Mentalis Depressor anguli oris * Limb length assessment = Tests of hip dislocation > Ortolani: > Barlow: » Telescoping: * Assessment of spinal alignment Page 9 of 13* Rotational profile Foot progression angie ER eR Pm oy Se ke TOE 7 9 TM A M5-19 20s 508 70) Internal hip rotation (gts) La 13 5 7 8 Mi 1315-19 We S057 Transmalieoier ads eee & TOT TH wise we seme External ip rotation Vd 87 8 W Wie Dy anny Internal hip rotation (boys) V3 5 7 9 1 1915-19 ae Soom ‘Thighfoot angio TW ew aoe oat o Sensory assessment o Balance assessment o Gait assessment Page 10 of 13» Problem List: Vi PwonMp > Initial Plan: No. ‘Objective MethodSession | Date | Therapist | Notes | Session | Date | Therapist | Notes | Session | Date | Therapist | Notes No, No. No. a 3 a > _ bees nll 5 _ . _-| 4 34 3 35 6 | 8 6 6 7 v7 7 8 a8 oe | | [ 9 39 8 10 20 70 it a 7 a a R 2B 3 | me cz) Fry a4 74 5 a5 16 6 76 a a 7 18 a 78 19 ~\a9. 8 20 50 30 2 st ai 2 2 2 B 53 8 2 34 a 5 55 a 26 56 86 2 37 a7 28 58 88 28 38 39 30 60 90 Page 12 of 13 we