SUBJECTIVE

Patient Profile
Name:
Age:
Gender:
Settings:
D.O.A:
D.O.AX:
DR Diagnose:
DR Mx:

Chief Complaint:

History
Present History:
Past History:
Personal History:
Medical History:
On Medication:

OBJECTIVE

Observation
General
Race:
Gender:
Posture:
General built:
Gait:

Local
Swelling:
Scars:
Muscle wasting:
External Appliances:
Deformity:

On Palpation
Temperature:
Tenderness:
Oedema:
Vital signs:

On Examination
Higher functions
Memory:
Intelligence:
Level of consciousness:
Behaviour:
Orientation:
Speech:

Cranial Nerves Examination

Name
Olfactory
Optic
Oculomotor

Trochlear
Trigeminal

Abducens
Facial

Test
Identify a familiar odour, e.g coffe, orange with one
nostril at a time
Read with one eye covered, detects objects or
movement
Follow the examiners finger, which moves up and
down and side to side, keeping the head in mid
position
As for oculomotor
Test facial sensation, clench teeth (the examiner
palpates the masseter and temporalis muscles)
As for oculomotor
Test ability to move the face, e.g close eyes tightly,
wrinkle brow, whistle, smile, show teeth

Abnormal Signs
Partial or total loss of smell
Altered or increased sense of smell
Visual fields defects, loss of visual
acuity, colour blind
Squint, ptosis, diplopia, pupil
dilation
Diplopia, squint
Trigeminal neuralgia, loss
mastication and sensation in eye,
face, sinuses and teeth
Gaze palsy
Bells palsy, loss of taste and ability
to close eyes

Vestibulocochlear

Glossopharyngeal
Vagus
Accessory

Hypoglossal

Examiner rubs index finger and thumb together noisily

beside one ear and silently beside the other. Patients
identifies the noisy side.
Swallow, evoke the gag reflex by touching the back of
the throat with a tongue depressor
As for glossopharyngeal
Rotate neck to one side and resist flexion, ie contract
sternocleidomastoid. Shrug shoulders against
resistance
Stick out tounge. Push tounge into left and right side
of the cheek

Sensory Examination
Superficial senses
Pain:
Fine touch:
Crude touch:
Temperature:

Deep senses
Pressure:
Vibration:
Joint position sense:

Cortical senses
Tactile localization:
Two point discrimination:
Steriognosis:

Reflex Examination
Superficial
Corneal:
Pupillary:
Cremastric:
Gag:

Tinnitus, deafness, vertigo, ataxia,

nystagmus
Loss of tongue sensation and taste,
reduced salivation, dysphagia
Vocal cord paralysis, dysphagia, loss
of sensation from internal organs
Paralysis of innervated muscles

Dysphagia, dysarthria, difficulty

masticating

Abdominal:
Plantar/Babinski:

Deep
Biceps jerk:
Triceps jerk:
Brachioradialis jerk:
Quadriceps/knee jerk:
TA/ankle jerk:

Motor Examination

Range Of Motion

Joints

Movements

Shoulde
r

Flexion

Elbow

Wrist

Hip

Knee
Ankle

Extension
Abduction
Adduction
M.rotation
L.rotation
Flexion
Extension
Supination
Pronation
Flexion
Extension
Rad deviation
Ul deviation
Flexion
Extension
Abduction
Adduction
Flexion
Extension
Dorsiflexion
Plantar flexion

Muscle Tone

Right
(active)

Right
(passive)

Left
(active)

Left
(passive)

diffrence

Muscle under stretch

Shoulder flexor
Shoulder extensor
Shoulder abductor
Shoulder adductor
Elbow flexor
Elbow extensor
Wrist flexor
Wrist extensor
Finger flexor
Finger extensor

Hip flexor
Hip extensor
Hip adductor
Hip abductor
Knee extensor
Knee flexor
Ankle plantarflexor
Ankle dorsiflexor
Ankle inversion
Ankle eversion

1- No increase in muscle tone

2- Slight increase in muscle tone, manisfested by a catch and release or by minimal resistance at the end of the
range of motion when the affected parts is moved in flexion or extension.
3- Slight increase in muscle tone, manifested by a catch followed by minimal resistance throughout the
remainder (less than half) at the ROM.
4- More marked increase in muscle tone through most of the ROM, but affected parts easily moved.
5- Considerable increase in muscle tone, passive movement difficult.
6- Affected parts rigid in flexion or extension.

ADL Assessment

Barthel Index
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Bowels:
Bladder:
Grooming:
Toilet use:
Feeding:
Transfer:
Mobility:
Dressing:
Stairs:
Bathing:
Total Score =

Berg Balance Scale

1.
2.
3.
4.
5.

Sitting to standing
Standing unsupported
Sitting with back unsupported
Standing to sitting
Transfers

6.
7.
8.
9.
10.
11.
12.
13.
14.

Standing unsupported with eye closed

Standing unsupported with feet together
Reaching forward with outstretched arm while standing
Pick up object from floor from a standing position
Turning to look behind over left and right shoulders while standing
Turn 360 degrees
Placing alternate foot on step or stool while unsupported
Standing unsupported one foot in front
Standing on one leg
Total Score :

Motor Assessment Scale (MAS)

1.
2.
3.
4.
5.
6.
7.
8.

Supine to side lying on intact side

Supine to sitting over the side of bed
Balanced sitting
Sitting to standing
Walking
Upper arm function
Hand movements
Advanced hand activities
Total Score:

Functional Independence Measure (FIM)

Self-Care
1. Eating
2. Grooming
3. Bathing
4. Dressing - Upper Body
5. Dressing - Lower Body
6. Toileting
Sphincter Control
7. Bladder Management
8. Bowel Management
Transfers
9. Bed, Chair, Wheelchair
10. Toilet
11. Tub, Shower
Locomotion
12. Walk/Wheelchair
13. Stairs
Communication
14. Comprehension
15. Expression

16.
17.
18.
19.

Social Cognition
Social Interaction
Problem Solving
Memory
Total Score:

Gait Assessment

Dynamic Gait Index

1.
2.
3.
4.
5.
6.
7.
8.

Gait level surface

Change in gait speed
Gait with horizontal head turns
Gait with vertical heads turns
Gait and pivot turn
Step over obstacles
Step around obstacles
Steps
Total Score:

Coordination Test
Finger to Finger:
Finger to nose:
Heel to shin:

Balance Test
Sitting
-Static:
-Dynamic:
Standing
-Static:
-Dynamic:

Physiotherapy Impression

Short Term Goal

Long Term Goal

Plan of Treatment

Home Exercise Program

Re-assessment

Review

Barthel Index of Activities of Daily Living

.

The Barthel Index

Bowels
0 = incontinent (or needs to be given enemata)
1 = occasional accident (once/week)
2 = continent
Patient's Score:
Bladder
0 = incontinent, or catheterized and unable to manage
1 = occasional accident (max. once per 24 hours)
2 = continent (for over 7 days)
Patient's Score:
Grooming
0 = needs help with personal care
1 = independent face/hair/teeth/shaving (implements
provided)
Patient's Score:
Toilet use
0 = dependent
1 = needs some help, but can do something alone
2 = independent (on and off, dressing, wiping)
Patient's Score:
Feeding
0 = unable
1 = needs help cutting, spreading butter, etc.
2 = independent (food provided within reach)
Patient's Score:

(Collin et al., 1988)

Scoring:
Sum the patient's scores for each item. Total possible scores
range from 0 20, with lower scores indicating increased
disability. If used to measure improvement after
rehabilitation, changes of more than two points in the total
score reflect a probable genuine change, and change on one
item from fully dependent to independent is also likely to be
reliable.

Transfer
0 = unable no sitting balance
1 = major help (one or two people, physical), can sit
2 = minor help (verbal or physical)
3 = independent
Patient's Score:
Mobility
0 = immobile
1 = wheelchair independent, including corners, etc.
2 = walks with help of one person (verbal or physical)
3 = independent (but may use any aid, e.g., stick)
Patient's Score:
Dressing
0 = dependent
1 = needs help, but can do about half unaided
2 = independent (including buttons, zips, laces, etc.)
Patient's Score:
Stairs
0 = unable
1 = needs help (verbal, physical, carrying aid)
2 = independent up and down
Patient's Score:
Bathing
0 = dependent
1 = independent (or in shower)
Patient's Score:
Total Score:

Berg Balance Scale

1. SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hand for support.
( )4
able to stand without using hands and stabilize independently
( )3
able to stand independently using hands
( )2
able to stand using hands after several tries
( )1
needs minimal aid to stand or stabilize
( )0
needs moderate or maximal assist to stand
2. STANDING UNSUPPORTED
INSTRUCTIONS: Please stand for two minutes without holding on.
( )4
able to stand safely for 2 minutes
( )3
able to stand 2 minutes with supervision
( )2
able to stand 30 seconds unsupported
( )1
needs several tries to stand 30 seconds unsupported
( )0
unable to stand 30 seconds unsupported
If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4.
3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL
INSTRUCTIONS: Please sit with arms folded for 2 minutes.
( )4
able to sit safely and securely for 2 minutes
( )3
able to sit 2 minutes under supervision
( )2
able to able to sit 30 seconds
( )1
able to sit 10 seconds
( )0
unable to sit without support 10 seconds
4. STANDING TO SITTING
INSTRUCTIONS: Please sit down.
( )4
sits safely with minimal use of hands
( )3
controls descent by using hands
( )2
uses back of legs against chair to control descent
( )1
sits independently but has uncontrolled descent
( )0
needs assist to sit
5. TRANSFERS
INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use two chairs (one with and one
without armrests) or a bed and a chair.
( )4
able to transfer safely with minor use of hands
( )3
able to transfer safely definite need of hands
( )2
able to transfer with verbal cuing and/or supervision
( )1
needs one person to assist
( )0
needs two people to assist or supervise to be safe
6. STANDING UNSUPPORTED WITH EYES CLOSED
INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.
( )4
able to stand 10 seconds safely
( )3
able to stand 10 seconds with supervision
( )2
able to stand 3 seconds
( )1
unable to keep eyes closed 3 seconds but stays safely
( )0
needs help to keep from falling
7. STANDING UNSUPPORTED WITH FEET TOGETHER
INSTRUCTIONS: Place your feet together and stand without holding on.
( )4
able to place feet together independently and stand 1 minute safely
( )3
able to place feet together independently and stand 1 minute with supervision

( )2
( )1
( )0

able to place feet together independently but unable to hold for 30 seconds
needs help to attain position but able to stand 15 seconds feet together
needs help to attain position and unable to hold for 15 seconds

8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING

INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the end of fingertips when arm is at 90 degrees. Fingers should not touch
the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use both arms when
reaching to avoid rotation of the trunk.)
( )4
can reach forward confidently 25 cm (10 inches)
( )3
can reach forward 12 cm (5 inches)
( )2
can reach forward 5 cm (2 inches)
( )1
reaches forward but needs supervision
( )0
loses balance while trying/requires external support
9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION
INSTRUCTIONS: Pick up the shoe/slipper, which is place in front of your feet.
( )4
able to pick up slipper safely and easily
( )3
able to pick up slipper but needs supervision
( )2
unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance independently
( )1
unable to pick up and needs supervision while trying
( )0
unable to try/needs assist to keep from losing balance or falling
10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING
INSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat to the right. Examiner may pick an object to look at directly behind the subject to encourage a better twist turn.
( )4
looks behind from both sides and weight shifts well
( )3
looks behind one side only other side shows less weight shift
( )2
turns sideways only but maintains balance
( )1
needs supervision when turning
( )0
needs assist to keep from losing balance or falling
11. TURN 360 DEGREES
INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.
( )4
able to turn 360 degrees safely in 4 seconds or less
( )3
able to turn 360 degrees safely one side only 4 seconds or less
( )2
able to turn 360 degrees safely but slowly
( )1
needs close supervision or verbal cuing
( )0
needs assistance while turning
12. PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED
INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touch the step/stool four times.
( )4
able to stand independently and safely and complete 8 steps in 20 seconds
( )3
able to stand independently and complete 8 steps in > 20 seconds
( )2
able to complete 4 steps without aid with supervision
( )1
able to complete > 2 steps needs minimal assist
( )0
needs assistance to keep from falling/unable to try
13. STANDING UNSUPPORTED ONE FOOT IN FRONT
INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your
forward foot is ahead of the toes of the other foot. (To score 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approximate the subjects normal
stride width.)
( )4
able to place foot tandem independently and hold 30 seconds
( )3
able to place foot ahead independently and hold 30 seconds
( )2
able to take small step independently and hold 30 seconds
( )1
needs help to step but can hold 15 seconds
( )0
loses balance while stepping or standing

14. STANDING ON ONE LEG

INSTRUCTIONS: Stand on one leg as long as you can without holding on.
( )4
able to lift leg independently and hold > 10 seconds
( )3
able to lift leg independently and hold 5-10 seconds
( )2
able to lift leg independently and hold 3 seconds
( )1
tries to lift leg unable to hold 3 seconds but remains standing independently.
( )0
unable to try of needs assist to prevent fall

( ) TOTAL SCORE (Maximum = 56)

MOTOR ASSESSMENT SCALE

Supine to Side-lying onto intact side (starting position: supine with knees straight)
1.
Uses intact arm to pull body toward intact side. Uses intact leg to hook impaired leg to pull it over. 2.
Actively moves impaired leg
across body to roll but leaves impaired arm behind.
3.
Impaired arm is lifted across body with other arm. Impaired leg moves actively & body follows as a block. 4.
Actively moves impaired arm
across body. The rest of the body moves as a block.
5.
Actively moves impaired arm and leg rolling to intact side but overbalances. 6. Rolls to intact side in 3 seconds
without use of hands.
Supine to Sitting over side of bed
1.
Pt assisted to the side-lying position: Patient lifts head sideways but cant sit up.
2.
Pt may be assisted to side-lying & is assisted to sitting but has head control throughout.
3.
Pt may be assisted to side-lying & is assisted with lowering LEs off bed to assume sitting. 4.
but is able to sit up without help.
5.
Pt able to move from supine to sitting without help.
6.
Pt able to move from supine to sitting without help in 10 seconds.

Pt may be assisted to side-lying

Balance Sitting
1.
Pt is assisted to sitting and needs support to remain sitting.
2.
Pt sits unsupported for 10 seconds with arms folded, knees and feet together & feet on the floor.
3.
Pt sits unsupported with weight shifted forward and evenly distributed over both hips / legs. Head and thoracic spine extended.
4.
Sits unsupported with feet together on the floor. Hands resting on thighs. Without moving the legs the patient turns the head and trunk to look
behind the right and left shoulders.
5.
Sits unsupported with feet together on the floor. Without allowing the legs or feet to move & without holding on the patient must reach
forward to touch the floor (10 cm or 4 inches in front of them) The affected arm may be supported if necessary.
6.
Sits on stool unsupported with feet on the floor. Pt reaches sideways without moving the legs or holding on and returns to sitting position. Support
affected arm if needed.
Sitting to Standing
1.
Pt assisted to standing any method.
2.
Pt assisted to standing. The patients weight is unevenly distributed & may use hands for support.
3.
Pt stands up. The patients weight is evenly distributed but hips and knees are flexed No use of hands for support.
4.
Pt stands up. Remains standing for 5 seconds with hips and knees extended with weight evenly distributed. 5.
Pt stands up and sits down
again. When standing hips & knees are extended with weight evenly distributed 6.
Pt stands up and sits down again 3 x in 10 seconds with hips &
knees extended & weight evenly distributed
Walking
1.
With assistance the patient stands on affected leg with the affected weight bearing hip extended and steps forward with the intact leg.
2.
Walks with the assistance of one person.
3.
Walks 10 feet or 3 meters without assistance but with an assistive device. 4.
Walks 16 feet or 5 meters without
a device or assistance in 15 seconds.
5.
Walks 33 feet or 10 meters without assistance or a device. Is able to pick up a small object from the floor with either hand and walk back in 25
seconds.
6.
Walks up and down 4 steps with or without a device but without holding on to a rail 3 x in 35 seconds
Functional Independence Measure (FIM) Instrument
ADMISSION

DISCHARGE

FOLLOW-UP

Self-Care
A. Eating
B. Grooming
C. Bathing
D. Dressing - Upper Body
E. Dressing - Lower Body
F. Toileting
Sphincter Control
G. Bladder Management
H. Bowel Management
Transfers
I. Bed, Chair, Wheelchair
J. Toilet
_

K. Tub, Shower
Locomotion
L. Walk/Wheelchair
M. Stairs
Motor Subtotal Score
Communication
N. Comprehension
O. Expression
Social Cognition
P. Social Interaction
Q. Problem Solving
R. Memory
Cognitive Subtotal Score

L
E
V
E

TOTAL FIM Score

LS

Independent
7
C
o

m
p
l
e
t
e
I
n
d
e
p

endence (Timely, Safely) 6 Modified

Independence (Device)
Modified Dependence
5 Supervision (Subject = 100%+)
4 Minimal Assist (Subject = 75%+)
3 Moderate Assist (Subject = 50%+)
Complete Dependence
2 Maximal Assist (Subject = 25%+)
1 Total Assist (Subject = less than 25%)
Note: Leave no blanks. Enter 1 if patient is not testable due to risk

NO HELPER

HELPER

DYNAMIC GAIT INDEX

DATE:

Grading: record the lowest category that applies.

1. Gait level surface: Instructions: Walk at your normal speed from here to the next mark (20).
(3) Normal: walks 20, no assistive devices, good speed, no evidence for imbalance, normal gait
pattern.
(2) Mild impairment: walks 20, uses assistive devices, slower speed, mild gait deviations.
(1) Moderate impairment: walks 20, slow speed, abnormal gait patters, evidence for imbalance.
(0) Severe impairment: cannot walk 20 without assistance, severe gait deviations or imbalance.
2. Change in gait speed. Instructions: Begin walking at your normal pace (for 5), when I tell you
go, walk as fast as you can (for 5). When I tell you slow, walk as slowly as you can (for 5).
(3) Normal: Able to smoothly change walking speed without loss of balance or gait deviation.
Shows significant difference in walking speeds between normal, fast and slow paces.
(2) Mild impairment: Is able to change speed but demonstrates mild gait deviations, or no gait
deviations but unable to achieve a significant change in velocity, or uses as assistive device.
(1) Moderate impairment: Makes only minor adjustments to walking speed, or accomplishes a
change in speed with significant gait deviations, or changes speed but loses balance but is
able to recover and continue walking.
(0) Severe impairment: Cannot change speeds, or loss balance and has to reach for a wall or be
caught.
3. Gait with horizontal head turns. Instructions: Begin walking at your normal pace. When I tell
you to look right, keep walking straight, but turn your head to the right. Keep looking to the right
until I tell you look left, then keep walking straight and turn your head to the left. Keep your head
to the left until I tell you, look straight, then keep walking straight, but return your head to the
centre.
(3) Normal: Performs head turns smoothly with no change in gait.
(2) Mild impairment: Performs head turns smoothly with slight change in gait velocity, i.e. minor
disruption to smooth gait path or uses walking aid.
(1) Moderate impairment: Performs head turns with moderate change in gait velocity, slows down,
staggers, but recovers, can continue to walk.
(0) Severe impairment: Performs task with severe disruption of gait, i.e. staggers outside 15 path,
loses balance, stops, reaches for wall.
4. Gait with vertical head turns. Instructions: Begin walking at your normal pace. When I tell you
to look up, keep walking straight, but tip your head and look up. Keep looking up until I tell you,
look down. Then keep walking straight and turn your head down. Keep looking down until I tell
you, look straight, then keep walking straight, but return your head to the centre.
(3) Normal: Performs head turns smoothly with no change in gait.
(2) Mild impairment: Performs head turns smoothly with slight change in gait velocity, i.e. minor
disruption to smooth gait path or uses walking aid.
(1) Moderate impairment: Performs head turns with moderate change in gait velocity, slows down,
staggers, but recovers, can continue to walk.
(0) Severe impairment: Performs task with severe disruption of gait, i.e. staggers outside 15 path,
loses balance, stops, reaches for wall.

F:\Intranet\BIRU website\physiotherapy section\Dynamic Gait Index v.doc

5. Gait and pivot turn. Instructions: Begin walking at your normal pace. When I tell you, turn and
stop, turn as quickly as you can to face the opposite direction and stop.
(3) Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance.
(2) Mild impairment: pivot turns safely in >3 seconds and stops with no loss of balance.
(1) Moderate impairment: Turns slowly, requires verbal cueing, requires several small steps to
catch balance following turn and stop.
(0) Severe impairment: Cannot turn safely, requires assistance to turn and stop.
6. Step over obstacle. Instructions: Begin walking at your normal speed. When you come to the
shoebox, step over it, not around it, and keep walking.
(3) Normal: Is able to step over box without changing gait speed; no evidence for imbalance.
(2) Mild impairment: Is able to step over shoe box, but must slow down and adjust steps to clear
box safely.
(1) Moderate impairment: Is able to step over box but must stop, then step over. May require
verbal cueing.
(0) Severe impairment: Cannot perform without assistance.
7. Step around obstacles. Instructions: Begin walking at normal speed. When you come to the
first cone (about 6 away), walk around the right side of it. When you some to the second cone (6
past first cone), walk around it to the left.
(3) Normal: Is able to walk safely around cones safely without changing gait speed; no evidence of
imbalance.
(2) Mild impairment: Is able to step around both cones, but must slow down and adjust steps to
clear cones.
(1) Moderate impairment: Is able to clear cones but must significantly slow speed to accomplish
task, or requires verbal cueing.
(0) Severe impairment: Unable to clear cones, walks into one or both cones, or requires physical
assistance.
8. Steps. Instructions: Walk up these stairs as you would at home.(i.e. using a rail if necessary. At
the top, turn around and walk down.
(3) Normal: Alternating feet, no rail.
(2) Mild impairment: Alternating feet, must use rail.
(1) Moderate impairment: Two feet to a stair, must use rail.
(0) Severe impairment: Cannot do safely.
TOTAL SCORE