Physio Initial Assessment Form: History

11/28/21, 11:45 PM Physio Initial Assessment Form
Patient: JAIPAL B, 21 years, M Bed: Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment
Form
Physio Initial Assessment Form
History
Informant
Self Relative
Mother

Name
Laxmi

Chief Complaints
Pain With Radiation
Pain Without Radiation
Stiffness
General Weakness
Balance and Gait Disorder
Pre Surgical Rehab
Post Surgical Rehab
SOB
UPDATE
https://live.ucchvas.com/ip-emr/physio_initial_assessment/717/facility/2 1/39
Incoordination
Form
Cognitive Dysfunction
Speech Disorder
Agility / Endurance Training
Delayed Milestones
ADHD
Autism Spectrum
Swelling
Wheeze
Vertigo
Dysphagia
Memory Loss Disorder
Tingling & Numbness
Others
Complains
of irritability, cannot speak, unable to sit or stand and Move in the bed
History of Present Illness
Motor Vehicle Accident

12/11/21
Accidental Fall
UPDATE
Head Injury
Spine Injury Form
Stroke
Diffuse
axonal injury,zygoma fracture,upper lip avulsion injury,left hand deglovi
Others
Treatment History
Medical Treatment
ICU Care
Ventilatory Support
Tracheostomy
Others
Surgical Treatment
Craniotomy
Spine Fixation
Fracture Fixation
Left zygoma fracture ORIF with

reconstruction of left eyelids,upper Collagen applicat
lip UPDATE
Patient: JAIPAL B, 21 Others

years, M Bed: Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment
Form
Past Medical History
Hypertension
Diabetes
IHD
CVA
TIA
Seizures
Asthma
COPD
CKD
Others
Past Surgical History
Yes No
Personal History
UPDATE
Patient: JAIPALMarital
B, 21 years, M
Status Bed: Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment
Form
Educational
Single Qualification
Married Divorced Widowed
Post Graduate Graduate High Schooling
Primary Schooling Uneducated
Smoking
Smoking Non Smoker Stopped Smoking
Alcohol
Alcoholic Social Drinking Non Alcoholic
Previous Functional Capacity
Independent Dependent Assisted Living
Bed Bound Wheel Chair Bound
Known Allergies
None Yes
Examination
General Examination
Built
UPDATE
Lean Cachectic Well Built Muscular
Form
Obese Morbidly Obese
Vitals at the time of Admission
Range - 94 to 106
Temperature
98 Degrees F
Range - 40 to 160
Pulse Rate
109 beats/min
Range - 6 to 60
Respiratory rate breaths/min

Range - 60 to 200
Systolic BP
128 mmHg
Range - 40 to 140
Diastolic BP
89 mmHg
Range - 75 to 100
SpO2
97 %
GCS SCALE
SHOW PROGRESSIVE SCALE
Glasgow Coma Scale
INFO 3 /15 :
Eye Opening
NT 1 2 3 4
Response
Verbal UPDATE
NT 1 2 3 4 5
Response
Form
Motor
NT 1 2 3 4 5 6
Response
Comments

Pain Scale
No Yes
Systemic Examination
Skin
Pressure Sores
Yes No
Soft Tissue Injury
None
Abrasions

Contusions
Bruises
UPDATE
Lacerations
Form
Left
devolving injury of left hand and left knee a Avulsion injury
Others
Scar
Yes No
Left side face, on knee

and
on hand
Surgical Incision
Yes No
Swellings
Yes No
Cardio Vascular System
Peripheral Pulses
Regular Irregular
UPDATE
Bounding Normal Volume Feeble
Form

JVP
Normal Raised
Heart Sounds
S1
S2
S3
S4
Respiratory System
UPDATE
Patient: JAIPAL B, 21

Typeyears, M Bed: Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment
Of Breathing
Form
Normal Apnea Tachypnea, Bradypnea,
Hyperpnea, Hyperventilation, Hypoventilation,
Orthopnea, Paradoxical ventilation,
Biot's Respiration, Cheyne-stoke's Breathing,
Kussmaul's Breathing, Sighing, Hoover's sign
Others
Auscultation
Normal Breath Sounds Abnormal Breath Sounds
Musculo Skeletal
Limb Deformity
No Yes
Fractures
Shoulder
Humerus
Fore Arm
Wrist
UPDATE
Hand
Patient: JAIPAL B, 21 years, M

Hip Bed: Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment
Form
Femur
Leg
Foot
Clavicle
Skull
Normal Fracture Soft Tissue Injury
Spine
Normal
Fracture Vertebrae
Cervical Spondylosis
Kyphosis
Scoliosis
Others
Joint Pain
UPDATE
None Yes
Form
Contractures
No Yes
ROM
Assessable Non Assessable
Range Of Motion
Shoulder Joint
Left Right
Action Active Passive Active Passive
Flexion Selec
Selec Selec Selec
0 - 180 0 - 180 0 - 180 0 - 180
Extension
Selec Selec Selec Selec
0 - 60 0 - 60 0 - 60 0 - 60
Abduction
Selec Selec Selec Sele
0 - 180 0 - 180 0 - 180 0 - 180
Adduction
180 - 0 180 - 0 180 - 0 180 - 0
Medical
Rotation 0 - 70 0 - 70 0 - 70 0 - 70
UPDATE
Lateral
Patient: JAIPAL B, 21 years, M Bed: Unit Selec
1 -2 -209 Selec
A.D: 25/11/2021
Selec Physio
SelecInitial Assessment
Rotation 0 - Form
90 0 - 90 0 - 90 0 - 90
Elbow Joint
Left Right
Flexion Selec
Selec Selec Selec
0 - 150 0 - 150 0 - 150 0 - 150
Extension
150 - 0 150 - 0 150 - 0 150 - 0
Forearm Joint
Left Right
Supination
Sele Sele Sele Sele
0 - 80 0 - 80 0 - 80 0 - 80
Pronation
0 - 80 0 - 80 0 - 80 0 - 80
Wrist Joint
Left Right
Action Active Passive Active Passive UPDATE
Flexion
Patient: JAIPAL B, 21 years, M Bed: Unit
1 -2 -209
Selec A.D: 25/11/2021
Selec Selec Physio
0 - 80Form 0 - 80 0 - 80 0 - 80
Extension
0 - 70 0 - 70 0 - 70 0 - 70
Radial
Deviation 0 - 20 0 - 20 0 - 20 0 - 20
Ulnar
Deviation 0 - 30 0 - 30 0 - 30 0 - 30
Thumb Joint
Left Right
CMC Selec
Selec Selec Selec
Flexion 0 - 15 0 - 15 0 - 15 0 - 15
CMC
Extension 0 - 20 0 - 20 0 - 20 0 - 20
CMC
Abduction 0 - 70 0 - 70 0 - 70 0 - 70
IP Selec
Selec Selec Selec
Flexion 0 - 80 0 - 80 0 - 80 0 - 80
Metacarpel Joint
Left Right
UPDATE
Action
Patient: JAIPAL B, 21 years, M Active
Bed: Unit Passive
1 -2 -209 Active Physio
A.D: 25/11/2021 Passive
Initial Assessment
Form
Flexion Selec
Selec Selec Selec
0 - 90 0 - 90 0 - 90 0 - 90
Hyperextension
Sel Sel Sel Sel
0 - 45 0 - 45 0 - 45 0 - 45
abduction
Sele Selec Selec Sele
0 - 45 0 - 45 0 - 45 0 - 45
Proximal Interpherengeal Joint
Left Right
Flexion Selec
Selec Selec Selec
0 - 100 0 - 100 0 - 100 0 - 100
Disital Interpherengeal Joint
Left Right
Flexion Selec
Selec Selec Selec
0 - 100 0 - 100 0 - 100 0 - 100
Hyperextension
Sel Sel Sel Sel
0 - 10 0 - 10 0 - 10 0 - 10
UPDATE
HIP Joint
LeftForm Right
Flexion Selec
Selec Selec Selec
0 - 120 0 - 120 0 - 120 0 - 120
Extension
0 - 30 0 - 30 0 - 30 0 - 30
Abduction
0 - 45 0 - 45 0 - 45 0 - 45
Adduction
0 - 30 0 - 30 0 - 30 0 - 30
Lateral
rotation 0 - 45 0 - 45 0 - 45 0 - 45
Medial
rotation 0 - 45 0 - 45 0 - 45 0 - 45
KNEE Joint
Left Right
Flexion Selec
Selec Selec Selec
0 - 150 0 - 150 0 - 150 0 - 150
Extension
150 - 0 150 - 0 150 - 0 150 - 0
UPDATE
ANKLE
Patient: JAIPAL B, 21 years, M Bed: Joint
Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment
Form
Left Right
Dorsifkexion
Sele Sele Sele Sele
0 - 20 0 - 20 0 - 20 0 - 20
Plantarflexion
Sele Sele Sele Sele
0 - 50 0 - 50 0 - 50 0 - 50
Foot Joint
Left Right
Inversion
0 - 35 0 - 35 0 - 35 0 - 35
Eversion
0 - 15 0 - 15 0 - 15 0 - 15
Great Toe Joint
Left Right
Flexion Selec
Selec Selec Selec
0 - 30 0 - 30 0 - 30 0 - 30
UPDATE
Extension
Patient: JAIPAL B, 21 years, M Bed: Unit 1 Selec

-2 -209 A.D:
Selec25/11/2021
Selec Physio
0 Form
- 80 0 - 80 0 - 80 0 - 80
Inter Phallengeal Joint
Left Right
Flexion Selec
Selec Selec Selec
0 - 50 0 - 50 0 - 50 0 - 50
Extension
50 - 0 50 - 0 50 - 0 50 - 0
Cervical Spine
Action Active Passive
Flexion
Select A Select A
0 - 45 0 - 45
Extension
Select A Select A
0 - 45 0 - 45
Right
Select A Select A
Rotation 0 - 60 0 - 60
Left
Select A Select A
Rotation 0 - 60 0 - 60
Right
Select A Select A
Lateral 0 - 45 0 - 45
flexion UPDATE
Left
Patient: JAIPAL B, 21 years, M Lateral
Bed: Unit 1 -2 Select
-209 A.D: 25/11/2021
A Select Physio
A Initial Assessment
flexion Form
0 - 45 0 - 45
Thoraco Lumbar Spine
Action Active Passive
Flexion
Select A Select A
0 - 80 0 - 80
Extension
Select A Select A
0 - 25 0 - 25
Right
Select A Select A
Rotation 0 - 35 0 - 35
Left
Select A Select A
Rotation 0 - 35 0 - 35
Right
Select A Select A
Lateral 0 - 45 0 - 45
flexion
Left Lateral
Select A Select A
flexion 0 - 45 0 - 45
Neurological Assessment
Mental Status UPDATE
RASS
Form
Richmond Agitation–Sedation Scale
1 : normal
-5 -4 -3 -2 -1 0
Unarousable Deep Moderate Light Drowsy Alert and
sedation sedation sedation calm
MOCA
Montreal Cognitive Assessment
INFO
Total: 0/ 30
Abnormal Cognition
Visual/Executive
- Begin-End
- Copy Cube
Contour 0
5
Numbers
Hands
UPDATE
Naming
Form
0
3
Memory
First Test Second Test

UPDATE
FACE
VELVET
Form
CHURCH
DIASY
RED
Attention
Repeat the following in forward order

21854
Repeat the following in backward order

742
Repeat the list and tap hand on occurence of 0

A
6
FBACMNAAJKLBAFAKDEAA
AJAMOFAAB
Serial 7 Subtraction starting at 100
93 86 79 72 65
Language
Repeat Test 1
I only know that John is the one to
help today
Repeat Test 2 UPDATE
The catBed:
Patient: JAIPAL B, 21 years, M always
Unithid
1 -2under the couch
-209 A.D: 0 Assessment
25/11/2021 Physio Initial
when the dogs were in the room
Form 3
Letter starting with F

Fluency/Name maximum number of
words in one minute that begin with
letter F
Abstraction
Similarity Test 1
Train - Bicycle
0
Similarity Test 2 2
Watch - Ruler
Delayed Recall
FACE
VELVET
CHURCH 0
5
DAISY
RED
Orientation
Date
UPDATE
Month Bed: Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment

Form
Year
0
6
Day
Place
City
Gait
Posture
Posture

Berg Balance Scale
UPDATE
Cranial Nerves
Form
Not assessable Normal Abnormal/Affected
Sensory System
Assessable Not Assessable
Sensation
Right Upper Extremity
Right Lower Extremity
Left Upper Extremity
Left Lower Extremity
Tactile Localization
2 Point Discrimination
Normal Absent
Stereognosis
Normal Absent
Graphesthesia
Normal Absent
Romberg's Sign
Positive Negative Not Assessable
UPDATE
Motor system
Form
MMT
Manual muscle testing
INFO
Left Right
Upper Limb Upper Limb

Lower Limb Lower Limb

MAS
Modified Ashworth scale
INFO
Left Right
Upper Limb Upper Limb

UPDATE
Form

Lower Limb Lower Limb

VCG
Reflexes
REFLEXES Left Righ
Biceps

Brachioradialis

Triceps

Knee

Ankle

Babinski's
UPDATE
RESET
Form
Coordination
Finger-to-nose test
Finger-to-finger test
Adiadokokinesia or dysdiadokokinesia
Rebound phenomena
Walking along a straight line
Rombergs test
Heel on shin test
TCMS
Trunk Control Measurement Scale
INFO 0 /58 :
static sitting Range - 0 to 20
balance
selective Range - 0 to 28
movement UPDATE

control
Form
dynamic Range - 0 to 10
reaching
Functional Status Assessment
Subjective Assessment
Vision
Normal Affected Non Assessable
Hearing
Normal Affected Non Assessable
Activities of Daily Living
Barthel Index
INFO 0 / 100 : Totally Dependent
0 5 10 15
Feeding
Bathing
UPDATE
Grooming
Form
Dressing
Bowels
Bladder
Tolet Use
Transfers(Bed to chair +
and back)
Mobility +
Stairs
Endurance
Assessable Not Assessable
RPE Scale
Rating of perceived exertion
INFO 5 : Moderate
Very Light Light Moderate Moderate Moderate V

Light
2 3 4 5 6
1
UPDATE
Six Minute Walk Test

Form
Six Minute Walk Test
Details
Gender
Male Female
Range - 0 to 150
Age* years

Range - 0 to 180
Height* cms

Range - 0 to 500
Weight* kgs

Pre vitals
Range - 40 to 130
Heart Rate* beats/mins

Range - 100 to 180
SBP* mmHg

Range - 60 to 110
DBP* mmHg

Range - 90 to 100
SPO2* %

Range - 12 to 30
RR* breaths/min

RPE

Post vitals
Range - 40 to 200
Heart Rate* beats/mins
UPDATE
Range - 100 to 240
SBP* Bed: Unit 1 -2 -209 A.D:
Patient: JAIPAL B, 21 years, M 25/11/2021 Physio Initial Assessment
mmHg
Form
Range - 60 to 140
DBP* mmHg

Range - 80 to 100
SPO2* %

Range - 12 to 60
RR* breaths/min

RPE

No of Laps *

Distance walked in meters *

Final partial lap in meters *

Mins
walked *
Reasons
for immediately stopping a 6MWT *
Speech and Swallow Assessment
Normal Abnormal
UPDATE
Investigations
Form
1 REQUEST INVESTIGATION
Date
Id Category SubCategory Note
Created
2021-
11-26
3 OtherTest Others LFT
08:12
am
2021-
11-26
2 OtherTest Others Rft
08:11
am
2021-
11-26
1 OtherTest Others Cbp
08:11
am
Functional Diagnosis
Cardio
Ortho
Sports
Neuro
Amyotrophic Lateral Sclerosis
Stroke
UPDATE
HeadinjuryBed: Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment

Form
Hemiplegia
Diplegia
Quadriplegia
Monoplegia
Hemiparesis
Diparesis
Quadriparesis
Monoparesis
Others
Spinal Cord Injury
Nerve Compression
Carpel Tunnel Syndrome
Aphasia
Ataxia
Parkinson's Disease
Multiple Sclerosis
ADHD
UPDATE
AUTISM
AUTISM
Bells Palsy Form
Cranial Nerve Injury
Brachial Plexus Injury
Cerebral Palsy
Dementia
Alzheimer's
GBS
Transverse Myelitis
Others
Therapeutic Goals
Ortho
Cardio
Sports
Neuro
Return to work if appropriate and/or previous level of functional

capacity
To promote independence in ADLs for those who are compromised
UPDATE
To reduce number of hospital admissions due to SOB, Chest
congestion
g
Learn healthy behaviors, such as regular exercise and a heart-
Form
healthy diet
Quit Smoking /Alcohol/Tobacco
Flexibility And Joint ROM
Strength And Endurance
Proprioception And Coordination
Control Pain And Swelling
Bladder And Bowel Retraining
Activities to improve mobility (movement), muscle control, gait

(walking), and balance
Social and behavioral skills retraining
Normalization of the muscle tone
Development of fine motor skills and self-care abilities
Promoting cognitive and speech skills
Stimulation of the long-term CNS development
Correction Of The Movement Stereotypes
Others

Therapy
UPDATE
Ortho
Cardio Form
Sports
Neuro
Stroke Rehab
4 weeks 6 weeks 8 weeks 12 weeks
Brustromme Approach

MRP Approach

NDT Approach

CIMT Approach

VOJTA Approach

PNF Approach

Electic Approach

ROODS Approach

Speech Therapy

UPDATE
Electrical
Mile StoneMuscle Stimulation
Training Form

Cognitive Rehab

Neuro Conditioning Training

Sensory Integration

ADL Training

Wheel Chair Training

Ultrasound
7 days 10 days 15 days
Splinting / Bracing
2 weeks 4 weeks 6 weeks 8 weeks
12 weeks
Postural Correction

Robotics

Gait Training

UPDATE
Treatment
Patient: JAIPAL plan Bed: Unit 1 -2 -209 A.D: 25/11/2021 Physio Initial Assessment
B, 21 years, M
Form
Ambulation Schedule
Twice a day Thrice a day
Recreation Schedule
Once a day Twice a day
Position Change Schedule
2nd Hourly 4th Hourly 6th Hourly
Physiotherapy Schedule
Once a day Twice a day
UPDATE

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11/28/21, 11:45 PM Physio Initial Assessment Form

Physio Initial Assessment Form

Pain With Radiation

Pain Without Radiation

Balance and Gait Disorder

Pre Surgical Rehab

Post Surgical Rehab

Agility / Endurance Training

Memory Loss Disorder

Tingling & Numbness

History of Present Illness

Motor Vehicle Accident

Left zygoma fracture ORIF with

Patient: JAIPAL B, 21 Others

Past Medical History

Past Surgical History

Post Graduate Graduate High Schooling

Primary Schooling Uneducated

Smoking Non Smoker Stopped Smoking

Alcoholic Social Drinking Non Alcoholic

Previous Functional Capacity

Independent Dependent Assisted Living

Bed Bound Wheel Chair Bound

Vitals at the time of Admission

SHOW PROGRESSIVE SCALE

Glasgow Coma Scale

INFO 3 /15 :

Soft Tissue Injury

Left side face, on knee

Cardio Vascular System

Patient: JAIPAL B, 21

Hyperpnea, Hyperventilation, Hypoventilation,

Orthopnea, Paradoxical ventilation,

Biot's Respiration, Cheyne-stoke's Breathing,

Kussmaul's Breathing, Sighing, Hoover's sign

Normal Breath Sounds Abnormal Breath Sounds

Patient: JAIPAL B, 21 years, M

Normal Fracture Soft Tissue Injury

Assessable Non Assessable

Action Active Passive Active Passive

Action Active Passive Active Passive

Action Active Passive Active Passive

Action Active Passive Active Passive UPDATE

Action Active Passive Active Passive

Proximal Interpherengeal Joint

Action Active Passive Active Passive

Disital Interpherengeal Joint

Action Active Passive Active Passive

Action Active Passive Active Passive

Action Active Passive Active Passive

Action Active Passive Active Passive

Action Active Passive Active Passive

Great Toe Joint

Action Active Passive Active Passive

Patient: JAIPAL B, 21 years, M Bed: Unit 1 Selec

Inter Phallengeal Joint

Action Active Passive Active Passive

Action Active Passive

Thoraco Lumbar Spine

Action Active Passive

Mental Status UPDATE

Richmond Agitation–Sedation Scale