: 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