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    Neurological Assessment:: Family History: Environmental History: Home: Floor: Stairs

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    Dounia A Odeh
    This document contains a patient's neurological assessment information including their name, age, gender, handiness, affected body part, occupation, medical history, family history, pain assessment, vital signs, range of motion testing, muscle strength testing, coordination, balance, gait, and short and long term rehabilitation goals.

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    Neurological Assessment:: Family History: Environmental History: Home: Floor: Stairs

    Uploaded by

    Dounia A Odeh
    58 views14 pages
    This document contains a patient's neurological assessment information including their name, age, gender, handiness, affected body part, occupation, medical history, family history, pain assessment, vital signs, range of motion testing, muscle strength testing, coordination, balance, gait, and short and long term rehabilitation goals.

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    neuro-assesment

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    This document contains a patient's neurological assessment information including their name, age, gender, handiness, affected body part, occupation, medical history, family history, pain assessment, vital signs, range of motion testing, muscle strength testing, coordination, balance, gait, and short and long term rehabilitation goals.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    58 views14 pages

    Neurological Assessment:: Family History: Environmental History: Home: Floor: Stairs

    Uploaded by

    Dounia A Odeh
    This document contains a patient's neurological assessment information including their name, age, gender, handiness, affected body part, occupation, medical history, family history, pain assessment, vital signs, range of motion testing, muscle strength testing, coordination, balance, gait, and short and long term rehabilitation goals.

    Copyright:

    © All Rights Reserved
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    of 14

    : Neurological assessment

    : Patient profile

    : Name : age : gender

    : Handiness : affected body : occupation

    : DOB: marital status : address

    :Date of onset : date of assessment : date of admission

    : Refried by : diagnosis doctor

    :Diagnosis PT

    : Chief complain

    : History

    : Present history

    : Past history : chronic diseases smoking and does : surgery

    :Allergic : child hood history

    : Medical history : medication : radiologist test

    : Family history

    Environmental history : home : floor : stairs :


    bathroom

    Social history: married/single : sons and daughter :


    : educational level

    : History review : cardiovascular : pressure sore

    : Musculoskeletal: neuromuscular : digestive and urinary


    : Pain

    :Type of pain

    :Location pain

    Intensity : when coma not used

    : Aggressive pain

    :Relieving pain

    : Objective

    : General observation : facial expressive : shoulder position

    : Vision : assistive devise : gait : balance

    : Posture

    : Localized observation : muscle wasting : pressure sore

    : Edema : dislocation : scar : temperature

    : Texture : color skin : tenderness

    : Vital sign : heart rate : respiratory rate : temperature

    :Blood pressure : tone

    Examination :- arousal Glasgow coma scale


    -: Cognition
    -: Attention

    -:Orientation : place: person: time

    -: Memory : declarative memory

    : Procedural memory

    - : Psychosocial function
    - : Sensation

    Left Right Sensation

    Superficial

    2 2 Light touch

    2 2 Pressure

    Deep Movement
    sense(dynamic
    2 2
    Position sense (static)
    2 2

    Combined

    Two-point discrimination

    2 2

    :Key to Grading 

    absent 1:impaired sensation 2: normal : 0 :

    -: Visual field

    -: Facial muscle

    - : Pharyngeal function

    - : Respiration and ventilation

    . Secretion

    Chest expansion.

    :Pattern of Breathing.

    :Synergistic pattern of movement

    : ROM and manual muscle testing


    Normal MMT AROM PROM MMT AROM PROM UL exam
    activeRO Rt
    M Lt Lt Rt
    170 Flx
    shoulder
    25 Ext.
    shoulder
    170 Abd.
    Shoulder
    30 Add.
    Shoulder
    85 ER
    shoulder
    70 IR
    shoulder
    155 Flx elbow
    0 Ext. elbow
    90 Supinatio
    n
    85 Pronation
    75 Flx wrist
    60 Ext. wrist
    80 Flx. finger
    35 Ext. finger

    Active MMT ARO PROM MMT AROM PROM LL Exam


    ROM M Rt
    Lt Rt
    Lt
    90 Flx. Hip

    25 Ext. Hip
    40 Abd. Hip
    0 Add. Hip
    45 ER Hip
    40 IR Hip
    150 Flx. Knee
    0 Ext. knee

    25 Ankle

    Dorsiflexi
    on
    35 Plantar
    flexion
    15 Inversion
    25 Eversion
    90 Flx. toes
    45 Ext. toes

    Trunk motion Muscle power**


    Extension from lumber spine
    Flexion from lumber spine
    Extension from thoracic spine
    Flexion from thoracic spine
    Rotation to left
    Rotation to right

    : Muscle tone spasticity

    Postural

    Anterior lateral posterior


    Head
    Cervical spine
    Shoulder
    Scapula
    Lumber spine
    Pelvic
    Hip
    knee
    Patella
    Ankle/foot

    : Coordination

    Coordination Assessment

    Patient Name: Date/Time of Exam:


    Examiner Name:

    Right Coordination Test Left


    Finger to nose
    finger to finger

    Finger opposition

    Pronation/supination

    Mass grasp

    Standing feet together


    (equilibrium)

    Standing

    Walk on heel or toes

    Walk in a circle

    Walk backward
    :Key Grading

    Activity impossible 2. Sever impairment 3. Moderate impairment .1


    4. Minimal impairment 5. Normal performance

    : Balance

    ) wheelchair :)0-20

    walking with assistive :)21-40(

    independent :)41-56(

    : Aerobic capacity and endurance

    minute walk test 6


    ________________________________________________: Name
    ______

    Assistive Device and/or Bracing Used

    ________:Date

    _____________ :Distance ambulated in 6 minutes

    : Gait

    :Heel strike (initial contact)

    :Loading response (foot flat )

    : Midstance

    :Terminal stance (heel of)

    :Preswing (toe off)

    : Initial &mid swing

    : Terminal swing

    :Functional independent measure


    : Problem list

    .1

    .2

    .3

    .4

    .5

    Short Goals Method Rep. & Patient


    exercise ( set&parameter position
    s

    :Long goal

    .1

    .2

    .3

    .4

    .5

    : Home program

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