Name:

DOB:

Medical Diagnosis:

Date:

History of Current Problem

What brings you in?

Age:

Sex: M/F

PT Diagnosis:

Date of Onset:

MOI: When did it begin? How long?

Duration:
Pain: Current: _____/10

At best: _____/10

At worst: _____/10

How would you describe your pain?

_____Sharp _____Dull _____Burning _____Aching _____Tingling_____ Numb _____Constant ____ Radiating

What aggravates it?

What relieves it?

Does it get worse at night? Y/N

Social/Home History
Single______ Married_____
Physical Activity:
Hobbies:
Use of Tobacco/Drugs/Alcohol:
Living Condition: Circle: Home/Apt.
Difficulties with any transfers:

Occupation: _____________________________Any limitations? Y/N

Stairs: Y/N
Toilet: Y/N

Any difficulties inside home? Y/N

please explain: ________________________________________________

Rails: Y/N
Shower: Y/N

Bed: Y/N

Chair: Y/N Car: Y/N

AD/DME:
Indoor: _________________
Outdoor_______________
Long distance: ___________
Medical History: (circle to what applies)
Medications: Do you take any prescription medications? Yes/ No
If yes, please list: Medication
Dosage
Frequency
_____________________________________________________________________
_____________________________________________________________________
Do you have any allergies? Yes/ No If yes, please list: ___________________________________________
Do you take any nonprescription medications or supplements? Yes/ No If yes, explain?
___________________________________________________
Have you ever had surgery? Yes/ No
Where:_______________________________
Date____/20_____
Where:_______________________________
Date___/20______
Within the past year have you had any of the following medical Tests? (check for what applies) Date:
___ MR___ Blood test___ Bone scan___ CT scan___ Doppler ultrasound___ EKG (electrocardiogram) ___ X-rays
___Other:
Previous falls? Y/N
Date:
Reason for stay:

Hospitalizations? Y/N
Recent falls? Y/N
Date:
Vision/Hearing correction? Y/N
Are you seeing any other HCP or seen a previous Physical Therapist?

Systems Review (Within the past year have you had any of the following symptoms?), circle all that apply
Musculoskeletal: Decrease balance, coordination,
Immunologic: change in skin or trouble sleeping
fatigue , numbness, memory loss, or joint pain
Endocrine: change in weight or hot flashes
Hematologic: rapid pulse or bleeding from nose
Hepatic/Biliary: Change in taste or smell
Genitourinary: less urination or pain with urination
Psychology: Rashes or recent skin change
Rheumatologic: muscle pain or weakness
Pulmonary: shortness of breath, cough up blood
Cardiovascular: chest pain or abnormal heart rhythms
Cancer: loss appetite or weight loss unexpected
Diabetes Mellitus: frequent urination or increase thirst
Gynecologic: bleeding or menstrual cycle pain
Gastrointestinal: change in bowel, diarrhea or constipation
Psychological: depressed, mood change, memory
Patient Goals
What were you able to do before the injury?
What do you hope to be able to do/want to do?

Vitals

HR:

Sensory Testing
Sensation
Light touch
Proprioception

BP: /

Key: 2=Intact
Findings +/- L/R

RR:

1=impaired
Sensation
Vibration
Graphesthesia

Tone- Modified Ashworth

Joints tested
Score
Shoulder
L
Elbow
Wrist
Fingers
Hip
Knee
Ankle
* Tone is graded according to Modified Ashworth Scale

O2 Sat:
0= Absent
Findings +/-

L/R

No increase in muscle tone

Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end
of the range of motion

1+
2

Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the
remainder (less than half) of the ROM
More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved

Considerable increase in muscle tone, passive movement difficult

Affected part(s) rigid in flexion or extension

Reflexes
Jaw Jerk
C5: Biceps
C6: Brachioradialis
C7: Triceps
C8: Finger flexors
L4: Quadriceps
S1: Triceps Surae

Scale for reflexes

0
1+
2+
3+
4+

MMT
L

No response
Present, but depressed
Average, normal
Increased, brisker than average
Very brisk, hyperactive, clonus

Muscle Groups

ROM

L
/180
/180
/70
/90
/150
/0
/80
/70
/120
/20
/40
/45
/45
/60
/0-10
/20
/50

Shoulder flexion
Shoulder ABD
Shoulder IR
Shoulder ER
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Hip flexion
Hip extensors
Hip ABD
Hip IR
Hip ER
Knee flexion
Knee extension
DF
PF
Cranial Nerve Examination
CN
CN I: Olfactory
CN II: Optic
CN III: Oculomotor
CN IV: Trochlear
CN V: Trigeminal
CN VI: Abducens
CN VII: Facial
CN VIII: Vestibulocochlear
CN IX: Glossopharyngeal
CN X: Vagus
CN XI: Spinal Accessory
CN XII: Hypoglossal

Intact: (+)
L

Impaired: ( )

R
/180
/180
/70
/90
/150
/0
/80
/70
/120
/20
/40
/45
/45
/60
/0-10
/20
/50

Absent= 0
R

Coordination Assessment:
Skill: non Equilibrium
Finger to nose
Tapping
Skill: Equilibrium
Tandem gait
Coordination: Gross
Berg Balance Scale
(0-4)
/56

Left

Right

Coordination: Fine
L
Buttoning
Sowing

Notes

Notes:

Handwriting

10

11

12

13

45/56 = high fall risk

Reciprocal
Movements
Upper Extremities
Lower Extremities

Symmetry

Motor Assessment
L
Muscle Tone
Hyper
Tremors
Present
Involuntary/uncontrolled movement Present
Muscle Atrophy
Present

Speed

Norm
Absent
Absent
Absent

FIM Scale
L

E
L

R
Hyper
Present
Present
Present

Hypo

Norm
Absent
Absent
Absent

Bed Mobility

7 Complete independence (Timely, Safety)

6 Modified Independence (Devices)

No Helper

Transfers

Modified Dependence
5 Supervision (Pt=100%)
4 Minimal Assist (Pt=75%)
3 Moderate Assist (Pt=50%)
Complete Dependence
2 Maximal Assist (Pt=25%)
1 Total Assist (Pt=less than 25%)

Helper

1. Bed, Chair, Wheelchair

2. Toilet
3. Tub, Shower
Locomotion

E
V

Fatigue?

1.
2.
3.

Walk
Wheelchair
Stairs

Social Cognition
1. Memory
2. Problem Solving

Hypo

Score

14

Post Polio:
Previous dx of polio
Gradual onset
Symptoms for at least a year
Fatigue
Muscle weakness
Joint and muscle pain
Cold intolerance
Spinal Cord Injury
MOI: Any injury/fall?
Loss of sensation
Loss of motor function
Loss of sensation/motor function with your
bowel/bladder
Tightness/ stiffness in muscles
Medical complications:
DVT: leg edema, increased temp, pain in leg,
erythema
Pressure Ulcers
Autonomic dysreflexia: severe/sudden BP,
pounding H/A, profuse sweating, anxiety,resp
Parkinsons Disease
Resting pill rolling tremor
Bradykinesia/slow movements
Postural Instability
Rigidity/difficult movements
Response to Sinemet/Levodopa
Loss of smell
Asymmetric Onset
Red Flags: UMN signs, Visual symptoms, Ataxia,
prominent sensory complaints, cognitive
impairments, early falls
ALS:
Muscle weakness, sensory physical mobility problems

Guillain-Barre
Weakness in arms AND legs, possibly face
Pain
Symmetry of symptoms
Any problems with HR, BP, sweating, dry
eyes/blurry vision
Problems breathing
Problems with reflexes
Hyper/abnormal sensation
Progressive Supranuclear Palsy:
>60 yrs
Postural instability
Loss of balance = more likely to fall backwards
Personality changes = loss of interest, irritability
Vertical gaze palsy (difficulty looking up and down)
Abnormal eye movements
Weakening of throat, mouth, and tongue
movements
Slurred speech
Dysphagia (difficulty swallowing)

Stroke
Right: lost feeling on left, weak on left, problems
with memory or neglect
Left: lost feeling on right, weak right, balance,
aphasia.
MS:
Fatigue, vision change, bowel, memory, pain, heat
intolerance. Spasticity, balance, tremor.
CP:
Abnormal muscle tone, reflexes, coordination, balance
problems, irregular posture, scissor gait and muscle
tightness.