AKSHAYA PHYSIOTHERAPY &

NEURO REHABILITATION
CLINIC
“ A STEP TO CURE ALL YOUR
PHYSICAL HEALTH PROBLEMS”

Website: www.rajuhospitals.com E-mail: rajuneuro@gmail.com Contact No: 98485 98616 ,

8801232323

--------------------------------DEPARTMENT OF
PHYSIOTHERAPY--------------------------------------

INFORMATION SHEET

Unique Code of the Recipient: PHOTOGRAPH

OF THE
Date of Admission :
RECIPEINT

ICD CODE :

Name & Address of Recipient :

Contact Numbers

Land line :

1
 Mobile :

Age & Sex :

Built & Nourishment : Well built/ Moderately built/ emaciated

Well nourished/ Moderately nourished/

malnourished

Height : Weight :

Body Mass Index :

Occupation :

Personal Details

• Alcoholism : None/ Occasional /Frequent/Regular

• Tobacco use : None/Occassional/Frequent/Regular

• Any other :

• Type of diet : Veg / Non-veg

(Occassional/Frequent/Regular)

Calorie intake /day :

Social status : Low /Middle /High income group

Medical History : DM / HTN / CAD / APD / TB / FITS / COPD / PVD / BPH /

LBA.

Diabetes mellitus : No

Duration :

Current blood sugar (R) :

Medications :

Hypertension : No

Duration :

Medications :

2
Surgical History :

Other significant disease (If any) :

Details of Injury

• Type of Lesion : Haemorrhage / Infarction

• Date of Onset :

• Location of lesion :

• Investigations :

CT Brain :

Others :

• Treatment done : Conservative / Surgical

Vital statistics

Temperature :

Heart rate :

Respiratory rate :

Blood pressure :

3
A. MENTAL STATUS
Responsiveness
Opens Eyes: Spontaneous Not spontaneously, only to voice Only to pain Not
at all
Behavior
Overall: Agitated Combative Inappropriate Restless
Motor Response: Follows commands Doesn't follow commands Localizing to pain
Flexion to pain Extension to pain No response to pain

Speech
Content: Comprehensive Inappropriate words Sounds, not words No speech
Clarity: Clear Slurred Unintelligible
Aphasia: None Expressive Receptive
Naming Objects: Accurate Inaccuracies

Orientation Normal
Is Disoriented to: Time Place Person

Memory None
Memory Problems: Short-term Long-term

B. CRANIAL NERVE DEFICITS

I Normal
Odors: Cannot smell odors Not tested

II Normal
R eye: Decreased acuity Field deficit No vision
L eye: Decreased acuity Field deficit No vision

III, IV, VI
EOM: Intact
R eye does not move: Down Up Out In Down+In
L eye does not move: Down Up Out In Down+In
Reports diplopia:

Pupils: Normoreactive
R: Sluggish Nonreactive Nonreactive pinpoint Nonreactive Dilated
No consensual reaction Hippus Right size > Left size
L: Sluggish Nonreactive Nonreactive pinpoint Nonreactive Dilated
No consensual reaction Hippus Left size > Right size
Ptosis: No R L
Nystagmus: No R L

4
V Intact
Touch sensation on face decreased: R L
For R face, pt reports: Pain Numbness Tingling
For L face, pt reports: Pain Numbness Tingling
Lack of corneal reflex on:
R Ipsilaterally Via consensual pathway

L Ipsilaterally Via consensual pathway

Chewing: Impaired Cannot chew

VII Intact
Weak eye closure: R L
Facial droop: R L

VIII Intact
Hearing impairment: R L

IX/X Intact
Swallowing: Impaired
Gag reflex: Reduced

XI Intact
Weak shoulder shrug: R L

XII Intact
Tongue deviates to: R L

C. PERIPHERY
Sensory (upper limbs, lower limbs): Intact
Decreased sensation: RU LU RL LL
Decreased discrimination of sharp from dull: RU LU RL LL
Decreased position sense: RU LU RL LL
Pt reports numbness: RU LU RL LL
Pt reports tingling: RU LU RL LL

Motor Strength:
(5=normal, 4=reduced, 3=weak against gravity, 2=weak even without gravity, 1=trace
contraction, 0=nothing)
RU 5 4 3 2 1 0
LU 5 4 3 2 1 0
RL 5 4 3 2 1 0
LL 5 4 3 2 1 0

Drift: RU LU

5
Specific weakness:
Hand grasp: R L
Upper arm push: R L
Upper arm pull: R L
Foot dorsiflex: R L
Foot plantarflex: R L

Coordination:
Impaired fine motor coordination: R hand L hand
Impaired rapid alternating movements: R hand L hand
Ataxia: RU LU RL LL
Gait: Impaired Not tested

Other:
Tremors: RU LU RL LL
Abnormal movements: RU LU RL LL

Reflexes (Reflex grading)

Deep tendon reflexes RIGHT

LEFT

Biceps

Triceps

Supinator

RIGHT LEFT

KNEE

ANKLE

Superficial reflexes

RIGHT LEFT
Abdominal reflex

Plantar reflex (Babinski’s Sign)

Range of Motion (Passive)

Right side Left side

Shoulder

-Abduction :
6
 -Flexion :

-Extension :

-Medial Rotation :

-Lateral Rotation :

-Shrugging :

Elbow

-Flexion :

-Extension :

Wrist

-Flexion :

-Extension :

Hip

-Abduction :

-Adduction :

-Flexion :

-Extension :

-Medial Rotation :

-Lateral Rotation :

Knee

-Flexion :

-Extension :

Ankle

-Plantar flexion :

-Dorsiflexion :

Sub-talar

-Inversion :

-Eversion :

7
Spasticity grading : (Modified Ashworth Scale)

Upper limb

➢ Biceps :

➢ Triceps :

➢ Pronator :

➢ Wrist & finger flexors :

Lower limb

➢ Knee extensor :

➢ Knee flexor :

➢ Plantar flexor :

➢ Invertors :

Contractures (If any) :

-Elbow :

-Forearm :

-wrist :

-finger :

-Hip :

-knee :

-Ankle :

-Subtalar :

Muscle girth measurement :

Right side Left side

8
 -Upper arm :

-Middle arm :

-Upper forearm :

-Middle forearm :

-Upper thigh :

-Middle thigh :

-Lower thigh :

-Upper leg :

-Lower leg :

Muscle power (Manual Muscle Testing)(MMT)

Right side Left side

Shoulder

-Abductors :

-Flexors :

-Extensors :

-Medial Rotators :

-Lateral Rotators :

Elbow

-Flexors :

-Extensors :

Wrist

-Flexors :

9
 -Extensors :

Hip

-Abductors :

-Adductors :

-Flexors :

-Extensors :

-Medial Rotators :

-Lateral Rotators :

Knee

-Flexors :

-Extensors :

Ankle

-Plantar flexors :

-Dorsiflexors :

Sub-talar

-Invertars :

-Evertars :

Synergetic pattern

Upper limb :

Lower limb :

Other abnormality (If any) :

10
 NEUROLOGICAL DISABILITY ASSESSMENT SCALES

GLASGOW-COMA SCALE
Eye opening

• None 1 Even to Pain (Supra-orbital Pressure)

• To Pain 2 Pain from Sternum/limb/supra orbital

ridge

• To speech 3 Non-specific response, not necessarily

command
• Spontaneous 4 Eyes open, not necessarily aware

Motor response

• None 1 To any pain: limbs ramain flaccid

• Extension 2 Decerebrate: Sholder adducted and

internally

Rotated, fore arm pronated.

• Abnormal Flexion 3 Decorticate: Shoulder flexes/

adducts

• Withdrawal 4 Arm withdraws from pain,

shoulder abducts

11
 • Localizes pain 5 Arm attempts to remove
supraorbital/ chest pain
• Obeys commands 6 Follows simple commands

Verbal Response

• None 1 As stated

• Incomprehnsible 2 Moans/Groans: No words

• Inappropriate 3 Intelligible, no sustained

sentences

• Confused 4 Responds with conversation, but

confused

• Oriented 5 Aware of time, place, person.

Score of the recipient: E( ) V ( ) M ( )

TRUNK CONTROL TEST

Tests (On bed)

1. Rolling to weak side

2. Rolling to strong side

3. Sitting up from lying down

4. Balance in sitting position (on side of bed)

Scoring:

0 - Unable to do on own

12 - Able to do, but only with non-muscular help. For example,

pulling on bed

Clothes, using arms to steady self when sitting, pulling up

on rope etc.,

25 - Able to complete normally.

12
 Trunk Score : Score (1)+(2)+(3)+(4)

Score of the recipient:

STANDING BALANCE SCALE

Grade Description

1 Unable to stand ( i.e,

worse than next grade)

2 Able to stand with feet

apart, but less than 30 seconds

3 Stand with feet apart for

30 seconds but not with feet together

4 Stand with feet together,

but less than 30 seconds

5 Stand with feet together,

30 seconds or more.

13
Score of the recipient:

BERG BALANCE SCALE

Date: ____________________________

Patient Name: ____________________________

Balance Item Score (0-4)

1. Sitting unsupported _______
2. Change of position: sitting to standing _______
3. Change of position” standing to sitting _______
4. Transfers _______
5. Standing unsupported _______
6. Standing with eyes closed _______
7. Standing with feet together _______
8. Tandem standing _______
9. Standing on one leg _______
10. Turning trunk (feet fixed) _______
11. Retrieving objects from floor _______
12. Turning 360 degrees _______
13. Stool stepping _______
14. Reaching forward while standing _______
14
TOTAL (0–56): _______

Interpretation
0–20, wheelchair bound
21–40, walking with assistance
41–56, independent

MANUAL MUSCLE TESTING SCALE

Grade Description

1 No
palpable Contraction of the Muscle

2 Flicker
of the contraction but no
movement seen

3 Move
ment in gravity eliminated plane,
should complete two thirds of ROM

4 Movem
ent against gravity without any

15
 resistance, should complete two
thirds of ROM

5 Movem
ent against gravity with minimal
Resistance, Complete ROM

6 Movem
ent against gravity with maximal
resistance, complete ROM

MODIFIED ASHWORTH SCALE FOR GRADING SPASTICITY

Grade Description

1 No increase in muscle tone

2 Slight increase in muscle tone,

manifested by a catch and release, or by
minimal resistance at the end of the range of
motion when the affected part(s) is moved in
flexion or extension

16
 3 Slight increase in muscle tone,
manifested by a catch, followed by minimal
resistance throughout the remainder (less than
half) of the range of movement (ROM)

4 More marked increase in muscle

tone through most of ROM, but affected part(s)
easily moved

5 Considerable increase in muscle

tone, passive movement difficult

6 Affected part(s) rigid in flexion or

extension

THE BARTHEL INDEX

Activity Score

FEEDING
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent ______

BATHING
0 = dependent
5 = independent (or in shower) ______

17
GROOMING
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided) ______

DRESSING
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.) ______

BOWELS
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent ______

BLADDER
0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent ______

TOILET USE
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping) ______

TRANSFERS (BED TO CHAIR AND BACK)

0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent ______

MOBILITY (ON LEVEL SURFACES)

0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards ______

STAIRS
0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent ______

TOTAL (0–100): ______

Guidelines

18
1. The index should be used as a record of what a recipient does, not as a record of what a recipient could
do.
2. The main aim is to establish degree of independence from any help, physical or verbal, however minor
and for whatever reason.
3. The need for supervision renders the recipient not independent.
4. A recipient's performance should be established using the best available evidence. Asking the recipient,
friends/relatives and nurses are the usual sources, but direct observation and common sense are also
important. However direct testing is not needed.
5. Usually the recipient's performance over the preceding 24-48 hours is important, but occasionally longer
periods will be relevant.
6. Middle categories imply that the recipient supplies over 50 per cent of the effort.
7. Use of aids to be independent is allowed.

CANADIAN NEUROLOGICAL SCALE - STROKE ASSESSMENT SYSTEM

Mentation

Level of consciousness Alert 3.0

Drow sy 1.5
Or i e n t a t io n Oriented 1.0
Disoriented or N/A 0 .0
Speech Normal 1.0
Expressive deficit 0.5
Receptive deficit 0.0
Motor Functions:

A1 No CommunicationDefic it

Face Symmetrical 0.5

Asymmetrical 0.0

Arm : Proximal
None 1.5
19
Mild 1.0
Sign ificant 0.5
Total 0.0

Arm : Distal
None 1.5
Mild 1.0
Significant 0.5
Total 0.0

Leg: Proximal
None 1.5
Mild 1.0
Significant 0.5
Total 0.0

Leg: Distal
None 1.5
Mild 1.0
Significant 0.5
Total 0.0

Motor Response:
A2 Comprehension Deficit
Face Symmetrical 0.5
Asymmetrical 0.0

Arms
Equal 1.5
Unequal 0.0

Legs
Equal 1.5
Unequal 0.0
Total Score

Pupil
Reaction
+ = reacts Right Size
- = no reaction Reaction
Sl = sluggish Left Size
C = closed Reaction

Vital Signs
Heart Rate :
Blood Pressure :
Temperature :
Respiration :
O2 Saturation :
20
Section: Mentation

(A) Level of Consciousness

i) Alert - Normal Consciousness
ii) Drowsy - Wakens when stimulated verbally but tends to doze off to sleep.

(B) Orientation
i) Oriented - To both place and time. Example: hospital or city plus month and year. If it is within
first few days of a new month, the previous month is acceptable. Speech can be
mispronounced or slurred, but intelligible.
ii) Disoriented or Non Applicable - If recipient can not answer place and time questions.
Example:
doesn’t know the answer, partial answer or cannot express answer in words or intelligible
speech.

(C) Speech - Testing for speech deficits.

i) Normal - Answers all questions and commands. Can be slurred but intelligible. Proceed to A1.
ii) Expressive - Show recipient 3 objects: pencil, key and watch. Ask the recipient to name all 3
objects. If recipient makes one or more errors and/or mispronounces words (slurred speech) or
non intelligible words (severe dysarthria) record as expressive deficit and proceed to A1. If the
recipient names all three objects, ask the recipient “what do you do with a key?...a watch?...and
a pencil? If the recipient answers all three, then they are normal speech. If they answer only 2
or less, then they are expressive speech.
iii) Receptive - Ask recipient to follow three commands: Close your eyes, point to the ceiling, and
wiggle toes. (Do not mimic commands.) If recipient follows all three, then proceed to expressive
deficit testing. If unable to obey all 3 commands, score receptive deficit and proceed to section

A2.

Section: A1 Weakness - No Comprehension Deficit (Expressive Deficit)

NOTE: When evaluating strength and range of motion in limbs, submit both limbs to same
testing. “R”or “L” identifies side with weakness. Only mark for the side with the greatest deficit
or variation.
(A) Face - None: Ask the recipient to show their teeth and grin. Is it symmetrical (even)?
Present: Ask the recipient to show their teeth and grin. Is it asymmetrical (uneven)?
(B) Arm - Proximal: (Test in sitting position if possible.) Apply resistance at midpoint between
shoulder and elbow, and ask recipient to elevate arms to 45 - 90 degrees. Monitor for weakness.
Arm - Distal: (Test in sitting or lying position.) Recipient makes fists and elevates arms, with
extended wrists. Check for full range of motion in both wrists, then proceed to apply resistance
separately to both fists while stabilizing the recipient’s arm firmly.
Section A1 Weakness (Continued)
(C) Leg: (Test recipient lying in bed)
Proximal: i) Hip Flexion - Have recipient flex thighs toward trunk with knees flexed at 90 degrees.
Apply resistance, one thigh at a time, to test for weakness.
Distal: ii) Dorsi Flexion of foot - Have recipient point toes and foot upwards. Apply resistance
to one foot at a time, to test for weakness.
Grading level of Weakness
i) None - No detectable weakness
ii) Mild - Normal range of motion against gravity but succumbs to
21
resistance either partially or totally.
iii) Significant - Cannot completely overcome gravity in range of motion
(only partial movement)
iv) Total - Absence of motion or only muscle contraction without movement.
Section A2 Motor Response - Comprehension Defect (Receptive Deficit)
(A) Face - Symmetrical: Ask the recipient to show their teeth and grin. Is it symmetrical (even)?
- Asymmetrical: Ask the recipient to show their teeth and grin. Is it asymmetrical (uneven)?
Note side.
(B) Arm - Place the arms outstretched at 90 degrees - one limb at a time. Note ability to maintain
a fixed posture for 3 - 5 seconds.
(C) Legs - Flex thighs with knees flexed at 90 degrees, one limb at a time. Note ability to
maintain a fixed posture for 3 - 5 seconds. If recipient is unable to cooperate, compare motor
response to a noxious stimulus (e.g. pressure on fingernail, toenail). Facial response (grimacing)
to pain is tested by applying pressure to the sternum.

Grading Level of Motor Response:

i) Equal - Recipient can maintain the fixed posture equally in both limbs for a few seconds or
withdraws equally on both sides to pain.
ii) Unequal - Recipient cannot maintain fixed position equally on either side or unequal
withdrawal to pain. Note side.

HEMISPHERIC STROKE SCALE

Date: ___________________________

Recipient Name: ___________________________

Rater Name: ___________________________

Score
Scored to give 0 ( = good) to 100 ( = bad)

LEVEL OF CONSCIOUSNESS

15 – Glasgow Coma Scale Score ______

LANGUAGE
Comprehension ______
Give three commands: ‘Stick out your tongue’ or “Close your eyes’ ‘Point to the door’
‘Place left/right hand on left/right ear and then on left/right knee (using unaffected side)
Score on number correctly followed: 0 = 5 1 = 4 2 = 2 3 = 0
Naming ______
Ask recipient to name the following items: Watch or Belt Watch strap or Belt buckle Index
finger or Ring finger
Score on number correctly named: 0 = 5 1 = 4 2 = 2 3 = 0
22
 Repetition ______
Ask the recipient to repeat the following: A single word, such as ‘dog’ or ‘cat’ ‘The
president lives in Washington’ ‘No ifs, ands, or buts’
Score on number repeated: 0 = 5 1 = 4 2 = 2 3 = 0

TOTAL _____

Fluency______
Score according to recipient’s spontaneous speech fluency, or Ask recipient to name as
many words as he can within one minute beginning with the letter ‘A’ (excluding proper
names)
Score as: 5 = Essentially no verbal output 3 = Moderately loss; inability to recognize
stationary finger, sees moving finger 1 = Mild loss; defect to double simultaneous
stimulation 0 = Normal

OTHER CORTICAL FUNCTIONS AND CRANIAL NERVES

Visual fields ______
Test clinically and score hemi-field loss as: 3 = Severe loss; inability to recognize moving
hand, no response to threat 2 = Moderate loss; inability to recognize stationary finger,
sees moving finger 1 = Mild loss: defect to double simultaneous stimulation 0 = Normal

Gaze ______
Score eye movements: 2 = Gaze play, or persistent deviation 1 = Gaze preference, or
difficulty with far lateral gaze 0 = Normal
Facial expression ______
Score movement: 3 = Severe weakness; drooling 2 = Moderate loss; asymmetry at rest 1 =
Mild weakness; asymmetry on similing 0 = Normal
Dysarthria ______
Score talking: 2 = Severe dysarthria 1 = Moderate dysarthria 0 = Normal
Dysphagia ______
Score swallow of glass water: 2 = Severe dysphagia 1 = Moderate dysphagia 0 = Normal
Neglect syndrome ______
Ask about weak limbs, and ask to bisect a line 7 inches (20 cm) long on piece of paper in
visual midline
Score: 2 = Anosagnosia, or denial of body part 1 = Consistently bisects line towards ‘good’
side of body 0 = Bisects line in middle
Visual construction ______
23
Ask recipient to copy three figure given, and score: 3 = Unable to copy any figure 2 = Can
copy a square 1 = Can copy a ‘Greek Cross’ (‘Cross of St. George’) 0 = Can copy 3D
drawing of cube
TOTAL _____

MOTOR FUNCTION
Arm, proximal ______
Arm, distal ______
Leg, proximal ______
Leg, distal ______
All scored 0-7 as: 7 = No movement (MRC 0) 6 = Trace movement only (MRC 1) 5 =
Motion without gravity only (MRC 2) 4 = Moves against gravity but not against resistance
(MRC 3) 3 = Moderate weakness (MRC 4 -) 2 = Mild weakness (MRC 4) 1 = Positive drift
of arm/leg (MRC 4 +) 0 = Normal (MRC 5)
Deep tendon reflexes ______
2 = Hypoactive or hyperactive 0 = Normal
Pathologic reflexes ______
2 = Babinski (plantar) and another abnormal 1 = Babinski (plantar) or another abnormal
0 = Normal
Muscle tone ______
2 = Increased or decreased 0 = Normal
Gait ______
Test ability to stand and walk, and score: 6 = Unable to stand unsupported or cannot
evaluate 5 = Can stand with support but cannot walk 4 = Severely abnormal; walking
distance limited even with support (from aid or person) 3 = Moderately abnormal; no
assistance required (apart from a stick/cane), but distance limited 2 = Mildly abnormal
(weak, uncoordinated); can walk independently but slowly 1 = Minimally abnormal, no
reduction in speed or distance 0 = Normal

SENSORY
Primary modalities (of affected side only), arm ______
Test touch, pain and score as: 4 = Anaesthesia 3 = Severe hypaesthesia 2 = Moderate
hypaesthesia or deficit only; or extinction to double simultaneous stimulation 1 = Mild
hypaesthesia or dysaesthesia 0 = Normal

TOTAL _____

Stereoagnosis ______
Test ability to distinguish two coins and a key, and score: 3 = Unable to achieve any
distinctions 2 = Can distinguish a coin from a key 1 = Can distinguish between two very
different sized coins (penny and ten-pence piece, penny and quarter) 0 = Can distinguish
24
 between two similar sized coins (penny and nickel, or two-pence piece and ten-pence
piece)
TOTAL _____

OVERALL TOTAL _____

Katz Index of
Independence
in Activities of
Daily Living
Activities
Dependence
Points (1 or 0)
Independence (0 Points)
(1 Point) WITH supervision,
NO supervision, direction direction, personal
or personal assistance assistance or total care
BATHING (1 POINT) Bathes self (0 POINTS) Need help with
Points: __________ completely or needs help bathing more than one
in bathing only a single part of the body, getting
part of the body such as in or out of the tub or
the back, genital area or shower. Requires total
disabled extremity bathing
DRESSING (1 POINT) Get clothes (0 POINTS) Needs help
Points: __________ from closets and drawers with dressing self or
and puts on clothes and needs to be completely
outer garments complete dressed.
with fasteners. May have
help tying shoes.

25
TOILETING (1 POINT) Goes to toilet,
Points: __________ gets on and off, arranges
clothes, cleans genital
area without help.
TRANSFERRING (1 POINT) Moves in and
Points: __________ out of bed or chair
unassisted. Mechanical
transfer aids are
acceptable
CONTINENCE (1 POINT) Exercises
Points: __________ complete self control over
urination and defecation.
FEEDING (1 POINT) Gets food from
Points: __________ plate into mouth without
help. Preparation of food
may be done by another
person.
(0 POINTS) Needs help
transferring to the toilet,
cleaning self or uses
bedpan or commode.
(0 POINTS)Needs help in
moving from bed to chair
or requires a complete
transfer.
(0 POINTS) Is partially or
totally incontinent of
bowel or bladder
(0 POINTS) Needs partial
or total help with feeding
or requires parenteral
feeding.

MATHEW STROKE SCALE

Date: ____________________________

Recipient Name: ____________________________

Rater Name: ____________________________

Activity Score

MENTATION

Level of Consciousness _______

8 = Fully conscious

6 = Lethargic but mentally intact

26
 4 = Obtunded

2 = Stuperous

0 = Comatose

Orientation (time, place, person) _______

6 = Oriented x 3
4 = Oriented x 2
2 = Oriented x 1
0 = Disoriented
SPEECH

0-23, according to Reitan test _______

CRANIAL NERVES

Homonymous hemianopsia _______

3 = Intact 2 = Mild 1 = Moderate 0 = Severe

Conjugate deviation of eyes _______

3 = Intact

2 = Mild

1 = Moderate 0 = Severe

Facial Weakness _______

3 = Intact

2 = Mild

1 = Moderate

0 = Severe

MOTOR POWER

Right arm _______

Right leg _______

Left arm _______

Left leg ______

5 = Normal strength

27
4 = Contracts against resistance

3 = Elevates against gravity

2 = Gravity eliminated

1 = Flicker

0 = No movements

PERFORMANCE, OR DISABILITY STATUS SCALE _______

28 = Normal

21 = Mild impairment 14 = Moderate impairment 7 = Severe impairment 0 = Death

REFLEXES _______

3 = Normal

2 = Asymmetrical or pathological reflexes

1 = Clonus

0 = No reflexes elicited

SENSATION _______

3 = Normal

2 = Mild

1 = Severe sensory abnormality

0 = No response to pain TOTAL ______

MODIFIED RANKIN SCALE (MRS)

Date: ___________________________

Recipient Name: ___________________________

Rater Name: ___________________________

Score Description

0 No symptoms at all

1 No significant disability despite symptoms; able to carry out all usual duties and
activities

28
2 Slight disability; unable to carry out all previous activities, but able to look after
own affair without assistance

3 Moderate disability; requiring some help, but able to walk without assistance

4 Moderately severe disability; unable to walk without assistance and unable to

attend to own bodilyneeds without assistance

5 Severe disability; bedridden, incontinent and requiring constant nursing care and
attention

6 Dead

TOTAL (0–6): _______

ORGOGOZO STROKE SCALE

Date: ___________________________

Recipient Name: ___________________________

Rater Name: ___________________________

Activity Score

CONSCIOUSNESS
0 = coma
5 = stupor
10 = drowsiness
15 = normal ______

VERBAL COMMUNICATION
0 = impossible

29
5 = difficult
10 = normal ______

EYES AND HEAD SHIFT

0 = forced
5 = gaze failure
10 = none ______

FACIAL MOVEMENTS
0 = paralysis
5 = normal ______

ARM RAISING
0 = impossible
5 = incomplete
10 = possible ______

HAND MOVEMENTS
0 = useless
5 = useful
10 = skilled
15 = normal ______

UPPER LIMB TONE

0 = increased or decreased
5 = normal ______

LEG RAISING
0 = impossible
5 = gravity
10 = resistance
15 = normal ______

FOOT DORSIFLEXION
0 = foot drop
5 = gravity
10 = resistance or normal ______

LOWER LIMB TONE

0 = increased or decreased
5 = normal ______

TOTAL (0–100): ______

30
Chief Complaints :

Associated complications :

Disability Evaluation :

Missing components :

31
Treatment Plan :

Home Program advised :

Signature of the Physiotherapist

32
 MEASUREMENT CHART OF DISABILITY

Unique code :

Name :

ICD :

Measurement Scale used :

Day 1 :

Day 16 :

Day 31 :

Day 46 :

Day 61 :

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Day 76 :

Day 91 :

RE-EVALUATION SHEET

Unique code : Date:

ICD CODE :

Achieved goals :

Present Limitations :

Disability Evaluation :

Treatment Plan :

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