INITIAL EVALUATION

Personal Data:
Name: Handedness:
Age: Room #:
Birthday: Date of IE:
Address: Physiatrist:
Sex: Date of Referral:
Nationality: Referring MD:
Civil Status: Date of Consultation:
Occupation: Medical Dx:
Height:
Weight: Meds:
Religion:
/S/: All information were taken from _____
C/C:
HPI:
Date of incident:
Pt’s activity during incident:
MOI:
Complaints p injury:
Pain (PPQRST):
Treatment:
When:
Where:
Attending physician:
Tests:
Imaging studies:
Results and Diagnosis:
Medications given:
Other/s:
1st PTR session:

PMH:
Previous hospital admissions:
Date:
Previous surgery:
Date:
FDA: [ ] Food, state:
[ ] Medications, state:
[ ] Others, state:

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Family Health History:
Disease Maternal Paternal Patient
DM
OA
RA
HTN
Cardiac Dse
Other

Significance:
Home situation:
Pt lives [ ] alone, [ ] with spouse, [ ] child/children, [ ] Other relatives, [ ] Group setting, [ ] Other:
in a: [ ] Private home/apartment, [ ] rented space [ ], assisted living/group home, [ ] Other:
Entrance to home:
# of bedrooms:
Devices and Equipment: [ ] wheelchair, [ ] cane, [ ] crutches, [ ] walker, [ ] other:
Transfer Methods:
Steps from entrance to Pt’s bedroom:
Obstacles/barriers (UE: overhead cabinets, door knobs, etc.; LE: elevations, ramps, stairs, etc.):
Other Relevant Information:
Pt Lifestyle:
Smoking pack-year:
Drug/alcohol intake:
Exercise habit:
Work:
Other hobbies:
Other Relevant Information:
Pt’s Goal:

/O/: TESTS AND MEASURES

I. OCULAR INSPECTION
Mental Alertness: Alert [ ], Lethargic [ ], Obtunded [ ], Stupor [ ], Coma [ ]
Conscious [ ], Coherent [ ], Cooperative [ ], as to place [ ], person [ ], time [ ]
General Appearance:
Body type: Ectomorph [ ], Mesomorph [ ], Endomorph [ ]
Body and breath odors: normal [ ], impaired [ ] (if impaired, specify ___________)
Method of transport: [ ] ambulatory, [ ] non-ambulatory
Assistive Device/s: [ ] None, [ ] if there is, state: _____________________
Posture:
Attachments: IV line [ ], L [ ] R [ ], others __________________
Deformities:
Swelling:
Discolorations of skin (cyanosis, jaundice, etc.)
Dyspnea: +1 [ ], +2 [ ], +3 [ ], +4 [ ]
Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 (Legend: +1 mild, only Pt notices; +2, mild, PT notices; +3, moderate, but continues activity; +4, severe, stops activity)
Gait deviations (if present and noticeable):
Others:
Palpation et Integumentary System
Tenderness: G1 [ ], G2 [ ], G3 [ ], G4 [ ]
(Legend: 1-℅ pain, 2-℅ pain & winces, 3-withdraws, 4-does not allow palpation)
Lymphedema/Edema: pitting [ ], non-pitting [ ], brawny [ ], weeping [ ], others [ ]
If pitting edema, specify grade _____
Skin assessment:
Texture:
Color:
Temperature et turgor:
Wound appearance:
Circulation:
Wound size et depth:
Scar:
Nail bed Ax: Capillary refill [ ], Beau’s lines [ ], Clubbing [ ], Others ____________
II. Cardiovascular Ax
Vital Signs Before During After Aspect
Temperature
Blood pressure
Respiratory
Rate
Pulse Rate
SPO2
Significance:

III. Pain Ax
Provokes
Palliative
Pattern
Quality
Region
Severity
Time
Significance:
III. NEUROLOGICAL ASSESSMENT:
100% intact as to pinprick, light touch, deep pressure, except:
SENSATIONS UE LE COMMENTS
RIGHT LEFT RIGHT LEFT
Pain
Temperature
Light Touch
Deep pressure
Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
2-pt Discrimination
Kinesthesia
Proprioception
Stereognosis
Sig.:
(Legend: 0 – absent, no response; 1 – impaired; 2 – intact)
Reflexes: Sig.:

(Legend: 0-areflexia, + = hyporeflexia, ++ =

normoreflexia, +++ = hyperreflexia, ++++ = clonus)

Cranial Nerve Assessment:

Function Findings
Cranial Nerve Test

I.Olfactory Smell
1. Test for Visual acuity.
Central: Snellen eye chart; test each eye
separately (covering other eye); test at
distance of 20 ft.
Vision
II. Optic 2. Test for peripheral vision.
Pupillary Reflexes 3. Test for pupillary reactions
(constrictions)

by shining light in eye light; if abnormal

test near reaction
1. Test for pupillary reactions
(constrictions) by shining light in
eye light; if abnormal test near
reaction
Pupillary Reflexes
III. Occulomotor 2. Patient is asked to look in each
direction and pursuit eye
Extraocular
movements (patient follows movin
Movements
finger). Observe position o eye and
test eye movements.

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 Muscles:
Medial, Superior, inferior rectus and
Inferior oblique

3. Elevates eyelid

1. Test eye movements Muscle:

Extraocular
IV. Trochlear
movement
Superior oblique

1. Test pain, light touch sensations:

forehead, cheeks, jaw (eyes close)
Sensory: Face
2. Test corneal reflex: touch light with
Sensory: Cornea
wisp of cotton
V. Trigeminal
3. Palpate temporal and masseter
Motor: Muscles of
muscles. Observe spontaneous
mastication
movements. Have patient clench
teeth, hold against resistance

1. Test eye movements Muscle:

VI. Abducens
Extraocular
Lateral Rectus
movement
1. Test motor function facial muscles. Raise
Facial Expression eyebrows, frown, show teeth, smile, close
eyes tightly puff out both cheeks
VII. Facial
Taste to anterior
2/3 of tongue 2. Apply saline solution and sugar solution
using a cotton swab
1. Test balance: Vestibulospinal function
(VSF)

Vestibular function Test eye-head coordination:

VIII. Vestibulocho-
Vestibulo-ocular reflex (VOR)
Chlear
Cochlear function
2. Test for auditory acuity Weber test

Rinne test
Sensory to 1. Apply saline solution and sugar solution
posterior 2/3 of using a cotton swab. Not typically tested.
tongue
IX. Glossopharyn-
2. Listen to voice quality
geal
Phonation
3. Examine for difficulty in swallowing glass
Swallowing of water

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 Palatal, pharynx
1. Have patient say “ah”; observe
control
motion of soft palate (elevates)
X. Vagus and position of uvula (midline)
Gag reflex
2. Stimulate back of throat lightly on
each side

Examine bulk and strength

Motor function
Trapezius
XI. Spinal Accessory Shrug both shoulders upward and against
Nerve resistance
Sternocleido-
Mastoid
Turn head to each side against resistance
Listen to patient’s articulation.
Tongue movements Examine resting position of the tongue.
XII. Hypoglossal Examine tongue movements: as patient

to protrude tongue and move side-to-sid

Significance:
MUSCULOSKELETAL ASSESSMENT
ROM: All major jts. of the body are WNL c N° end-feel as to PROM & AROM except:
JOINT NORMAL AROM DIFF PROM DIFF END-FEEL
MOTION RANGE R L R L R L R L R L
Capital 0-45
Flexion
Capital 0-45
Extension
L head 0-60
rotation
R head 0-60
rotation
Shoulder 0-180
Flexion
Shoulder 0-60
Extension
Shoulder IR 0-45
Shoulder ER 0-90
Shoulder 0-180
Abduction
Shoulder 180-0
Adduction
Elbow 0-150
Flexion
Elbow 150-0
Extension

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
Forearm 0-80
pronation
Forearm 0-70
supination
Wrist flexion 0-80
Wrist 0-70
extension
Wrist ulnar 0-30
deviation
Wrist radial 0-20
deviation
Thumb 0-15
flexion
Thumb 20-80
Extension
Thumb 0-70
Abduction
Thumb 0-15
Adduction
MCP flexion 0-90
MCP 0-45
extension
PIP flexion 0-80
PIP Extension 0-20
Finger 0-25
abduction
Finger 25-0
adduction
Hip Flexion 0-120
Hip 0-20
Extension
Hip Internal 0-45
Rotation
Hip External 0-45
Rotation
Hip 0-40
Abduction
Hip 0-20
Adduction
Knee Flexion 0-135
Knee 135-0
Extension
Ankle 0-20
Dorsiflexion

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
Ankle 0-50
Plantarflexio
n
Ankle 0-35
Inversion
Ankle 0- 15
Eversion

Significance:
MMT: All major muscles of the body are graded 5/5 except:
Grade
Muscle Group Muscles
L R
Shoulder
Anterior deltoid
Flexors
Shoulder
Latissimus dorsi
Extensors
Shoulder
Pectoralis major, Latissimus dorsi, Anterior
Internal
deltoid, Teres Major
Rotators
Shoulder
External Infraspinatus, Teres minor, Subscapularis
Rotators
Shoulder
Deltoid, Supraspinatus
Abductors
Shoulder
Pectoralis major, Latissimus dorsi
Adductors
Shoulder Hor
Pectoralis Major
Add
Shoulder Hor
Deltoid
Abd
Elbow Flexors Biceps brachii, Brachioradialis
Elbow
Triceps, Anconeus
Extensors
Forearm
Pronator teres, Pronator quadratus
Pronators
Forearm
Biceps Brachii
Supinators
Wrist flexors FCU, palmaris longus, FCR
Wrist Extensors ECU, EDC, ECRL, ECRB
Wrist Ulnar
ECU, FCU
Deviators
Wrist Radial
ECRL, ECRB, FRC
Deviators

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 Hip flexors Iliopsoas, Sartorius, TFL, Rectus Femoris
Hip Extensors Gluteus Maximus, Hamstrings
Hip Internal Gluteus Medius, Gluteus Minimus, Tensor
Rotators Fascia Lata
Piriformis, Obturator Externus, Obturator
Hip External
Internus, Superior Gemellus, Inferior Gemellus,
Rotators
Quadriceps Femoris, Sartorius
Hip Abductors Gluteus Medius, Gluteus Minimus, Sartorius
Add Longus, Add Brevis, Add Magnus, Add
Hip Adductors
Gracilis, Pectineus
Knee Flexors Quadriceps Femoris
Knee Extensors Hamstrings, Popliteus, Gastroc, Sartorius
Ankle
Gastrocnemius, Soleus, Plantaris
Plantarflexors
Ankle
Tibialis Anterior, EDL, EHL, Peroneus Tertius
Dorsiflexors
Ankle Evertors Peroneus Longus, Peroneus Brevis
Ankle Invertors Tibialis Posterior

Significance:
(Legend: )
GRADE TITLE DESCRIPTION

5 Strong Strong manual resistance, against gravity, full available ROM

4+ Good plus Nearly strong manual resistance, against gravity, Full available ROM
4 Good Moderate Manual Resistance, Against Gravity, Full available ROM

4- Good minus Nearly moderate manual resistance, against gravity, full available ROM

3+ Fair plus Slight manual resistance, against gravity, full available ROM

3 Fair No Resistance,Against Gravity, Full available ROM

3- Fair minus No resistance, against gravity, at least 50% ROM

2+ Poor plus Slight manual resistance, gravity minimized, full available ROM

2 Poor No Manual Resistance, Gravity minimized, Full available ROM

2- Poor minus No resistance, gravity minimized, minimal observable motion (at least 50% RO)

1+ Trace plus No resistance, gravity minimized, minimal observable motion (less than 50% ROM)

1 Trace Palpable muscle contraction, not resistance, no movement

0 Zero No palpable, observable, muscle contraction

IV. Anthropometric Measurement:

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
Chest Expansion Measurement:
Landmark Inspiration Expiration Difference

Axilla

Xiphoid Process (T6)

T10
Significance:

Limb Girth Measurement:

Region or location of edema: Landmark or reference:
In relation to the Right Left Difference
reference
4 inches above
2 inches above
2 inches below
4 inches below
Significance:

Figure of Eight Measurement:

Landmark Right Left Difference

Ulnar styloid process

Lateral tibial condyle

Medial Malleolus
Significance:

Muscle Bulk Test:

Region or location of atrophy: Landmark or reference:
In relation to the Right Left Difference
reference
4 inches above
2 inches above
2 inch below
4 inch below
Significance:

Leg Length Discrepancy

R (cm) L (cm) Difference (cm)

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 True Leg Length

Apparent Leg Length

Significance:

Amputation Screening:

Bone length
(transtibial limbs measured from medial tibial plateau; transfermoral limbs measured from ischial tuberosity or greater
trochanter)
Landmark L (cm) R (cm)

Soft Tissue Length

Landmark L (cm) R (cm)

Residual Limb Shape (conical, cylindrical, bulbous, etc.)/Abnormalities:

Shape Abnormalities L R

POSTURAL ASSESSMENT
Anterior

Head

Head aligned, extended, flexed

Shoulders symmetrical, L/R side higher?

Rib cage Symmetrical, rib hump?

Pelvis R/L ASIS higher?

Hips R/L hip higher, flexed, extended?

Knees R/L knee higher?, flexed/extended?

Feet intoeing, out toeing?

Posterior

Head

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 Shoulders

Scapula L/R scapula more elevated/prominent?, normal

Spine deviations?

Pelvis R/L PSIS higher? aligned?

Popliteal Fold R/L higher?

Lateral

Head aligned?

Thoracic Kyphosis normal?

Lumbar lordosis normal?

Knees L/R knee hyperextended/flexed?

Feet longitudinal arch present? otherS

Significance:

V. Balance/Tolerance Test
POSITION BALANCE GRADING TOLERANCE GRADING

Static Dynamic

Standing

Sitting
Significance:
Legend:
Static Balance
Normal: Able to maintain balance without steady support
Good: Able to maintain balance without support, limited postural sway
Fair: Able to maintain balance with handheld support, may require occasional minimal assist
Poor: Pt requires handhold and moderate to maximal assistance to maintain posture
Zero: Cannot Assume Position
Dynamic Balance
Normal: Accepts maximal challenge, weight shift easily within full range in all directions
Good: Accepts moderate challenge, maintain balance while picking object off floor
Fair: Accepts minimal challenge, able to maintain balance while turning head/trunk
Poor: Unable to maintain balance with challenge or movement
Zero: Cannot assume position
Tolerance:
Poor - <15min, Poor +- 15- 30 min, Fair- 30- 45 min., Fair +- 45- 60 min., Good- >60 min.
GAIT ASSESSMENT
REFERENCE LIMB:
BODY DEVIATION HS FF MST HO TO ACC MSW DEC
SEGMENT

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 Foot flat

Ankle Foot slap

and
Foot No Heel off

No Toe off

Exc PF

Exc DF

Toe drag

C/L Vault

Exc flexion

Limited Flexion
Hip
Hyperextension

No flexion

Exc Flexion

Limited flexion

Exc Flexion
Knee
No flexion

Hyperextension
Significance:

VII. General Functional Assessment

Activity or Function Levels of independence/amount Type of skilled assistance
assistance given to patient given to the patient

Bed activities
Moving in bed
Managing pillows and blankets
Reaching for objects
Sitting up

Hygiene activities
Brushing teeth
Bathing and showering
Washing
Toileting
Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 Combing hair
Eating activities
Using utensils
Managing glass and cup
Dressing activities
Putting on clothes
Tying laces
Putting on socks and shoes
Transfer activities
Bed to chair
Sit to stand
Getting into car
Walking activities
Level and uneven surface
Curbs and stairs
Opening doors
Walking and carrying items

Significance:

Legend for lvl of independence/skilled assistance given to patient:

NO HELPER: 7 – Complete Independence, 6 – Modified Independence
HELPER: 5 – Supervision, 4 - Minimal Contact Assistance, 3 – Moderate Assistance, 2 – Maximal Assistance, 1 – Total Assistance

Other Assessment Tools:

For neck: https://www5.aaos.org/uploadedFiles/NDI.pdf
For UE: https://dash.iwh.on.ca/sites/dash/public/translations/QuickDASH_English_Australia.pdf
For LBP: https://www.physio-pedia.com/Fear%E2%80%90Avoidance_Belief_Questionnaire;
https://www.rehab.msu.edu/_files/_docs/Oswestry_Low_Back_Disability.pdf
For Knee:
https://www.worksafe.qld.gov.au/__data/assets/pdf_file/0022/24097/knee-injury-and-osteoarthritis-outco
me-score-koos1.pdf
For Hip:
https://www.orthopaedicscore.com/scorepages/hip_disability_osteoarthritis_outcome_score_hoos.html
For ankle and foot:
https://www5.aaos.org/uploadedFiles/PreProduction/Quality/Measures/Foot%20and%20Ankle%20Ability%
20Measure.pdf
IX. AEROBIC Ax
TEST PROCEDURE RESULT INDICATION

6MW Test Two cones are set up 5 meters apart. The

object of this test is to walk as far as possible
for 6 minutes. Pt will walk back and forth
within the distance covered by the cones. Tell
the Pt, “Six minutes is a long time to walk, so
you will be exerting yourself. You are
permitted to slow down, to stop, and to rest
as necessary. You may lean against the wall
while resting, but resume walking as soon as
Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
 you are able. You will be walking back and
forth around the cones.”

PT will record the total distance covered by

the patient within 6 minutes.

TUG test Patients wear their regular footwear and can

use a walking aid, if needed. The patient
starts in a seated position. The patient stands
up upon the therapist's command: walks 3
meters, turns around, walks back to the chair
and sits down. The time stops when the
patient is seated. PT should document the
assistive device used.

PT will record the total time covered by the

patient.

IX. SPECIAL TEST

TEST PROCEDURE RESULT INDICATION

Significance:

/A/:
Practice Pattern:
Problem List:
1.
2.
3.
4.
LTG:
1.
STG:
1.
2.
3.
4.
Prognosis:
/P/: Pt will be seen as an ____ for ____ wks/sessions ____ hrs per session
Plan of Care:
1.
2.
3.
4.
Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph
Home Exercise Program:
1.
2.
3.
4.
Precautions:
RED FLAG SIGNS:

PREPARED BY:

BSPT-5, Interns, SWU-Phinma

Southwestern University Villa Aznar, Urgello St. Cebu City Philippines 6000 T +63. 32. 415. 5555 | www.swu.edu.ph