PEDIATRIC PHYSIOTHERAPY ASSESSMENT

Name: Father’s name:

Mother’s name: Age:

Sex: Date of birth:

Address: Phone number:

Referred by: Referring diagnosis:

Date of referral: Birth history:

Ex-premature ( )
Premature ( )
Term ( )
Post-term ( )

DATE OF ASSESSMENT

FAMILY HISTORY

First cousin marriage Yes ( ) No ( )

Mother’s health: Father’s health:

Siblings Number :
Age :
Disabilities:

DURING BIRTH
Prolonged labour

Short labour

Sudden birth

Birth injury

Birth asphyxia

Minutes until baby cried

AFTER BIRTH

Jaundice: Length of stay:

Treatment received: UV light:

Oxygen: Dehydration:

Pneumonia: Seizures:

Medication: Others:

INVESTIGATIONS

CT scan result

EEG result
X-ray

Others

MEDICATION TREATMENT

Drug history (any present meds) Name:

Therapy treatment: Reason:

When:
Where:
How long:
What was included:

VISION

Fixing: Tracking:

Horizontal: Vertical:

Nystagmus: Glasses:

Squint:

COMMUNICATION

DOES THE CHILD COMMUNICATE BY:

Crying: Facial expression:

Making gestures/sign : Making sounds:

Speaking words: Speaking sentences:

Any other means:

SENSORY SKILLS

NORMAL/HYPO/HYPER RESPONSE

Tactile: Visual:

Auditory: Vestibular:

Proprioceptive:

NEUROMUSCULAR STATUS

Tone (upper limb) Tone (lower limb)

Tone (trunk) Range of motion (upper limb)

Range of motion (lower limb)

FUNCTIONAL GROSS MOTOR

Sitting: Crawling:

Standing: Cruise alone furniture:

Walking: Jumping:

Running: Ball skills:

TRANSITIONAL MOVEMENTS

Rolling: Pivot prone:

Supine to sit: Prone to sit:

Sit to stand: Sit to side lying/prone:

Half kneel to stand: Stand to sit:

POSTURAL CONTROL

Supine: Prone:

Sit (dynamic/static): Standing:

Prone extension: Supine extension:

CLINICAL OBSERVATION

Contractures: Flat feet:

Hyperextend knee: Dislocation:

Deformities: Others:

AUTOMATIC REACTION

Equilibrium reaction: Protective reaction:

GRAVITATIONAL INSECURITY
 PRIMITIVE REFLEX

ATNR (Asymmetric tonic neck STNR (symmetric tonic neck

reflex): reflex):
Moro reflex: Landau reflex:

Flexor withdrawal: Labyrinthine reflex:

Palmar reflex: Babinski (plantar) reflex:

Galant reflex: Stepping reflex:

Rooting reflex: Others:

PERCEPTUAL MOTOR

Body awareness: Body co-ordination:

Bilateral integration:

VISUAL PERCEPTION

Visual discrimination: Visual memory:

Visual figure ground: Visual spatial:

COGNITIVE SKILLS

Level arousal: Attention/ hyperactivity /attention

span:
Problem solving: Able to follow instructions:

FINE MOTOR SKILLS

DOMINANCE: RIGHT ( ) LEFT ( )

Reach: Grasp type:

Release: Symmetrical use:

Bilateral use: In-hand manipulation:

Eye hand co-ordination: Transfer:

Writing skills: Others:

BEHAVIOUR

Aggression: Hyperactivity:

Following instructions: Interaction with others:

Discipline: Others:
 OCCUPATIONAL PERFORMANCE

Feeding: Bursting teeth:

Dressing: Toilet:

Bathing: Others:

ORAL MOTOR REFLEX

OBSERVATION (TONE/REFLEXES AND ORAL MOTOR CONTROL)

Behavior and interaction in Posture in feeding:

feeding:

Type of food: Drooling:

Choking/Gagging: Chewing:

Swallow: Drinking:

Suck: Tongue thrust:

 GENERAL OBSERVATION

MUSCLE TONE

-Decreased, minimal/moderate/maximum increased

-Fluctuating present at rest/with movement

-Predominant posture, right/left

Upper limb (right): Upper limb (left):

Lower limb (right): Lower limb(left):

Trunk: Neck:

PASSIVE RANGE OF MOVEMENT

-WNT (within normal limit)

-ERT (end range tightness)

-measure degrees with goniometry if any limitations

HIP RIGHT LEFT

Extension
Flexion
Abduction
Adduction
Rotation

KNEE RIGHT LEFT

Flexion
Extension
Dorsi flexion
Plantar flexion
Inversion
Eversion
Toes

SHOULDER RIGHT LEFT

Flexion
Extension
Abduction
Rotation

ELBOW RIGHT LEFT

Flexion
Extension
Supination
Pronation

WRIST RIGHT LEFT

Flexion
Extension
Finger

SPINE ROM

FUNCTIONAL GROSS MOTOR

Note the posture of the child’s head, shoulders, arm, trunk, pelvis,
knee, feet, weight bearing, symmetry and tone patterns or abnormal
reflex activity.

Ability to get in/out of position, to maintain it, support needed to be

symmetrical, to maintain head control to either side to bear and shift
weight, and presence and effectiveness of protective and equilibrium
reaction, co-ordination comment in muscle strength if appropriate.

Prone: Supine:
Bridging: Box sitting:

Long sitting: Cross sitting:

4 point kneeling: Crawling:

Squatting: High kneeling:

½ kneeling: Standing:

Kneel walking: Gait:

Stairs: Single leg stance:

Jumping: Ball skills:

Running: Hopping:

TRANSITIONAL MOVEMENTS

Rolling supine to prone

Prone to supine

Continuous rolling
Lying to sit

Box sit to stand

Cross sit to stand

Fine motor function

Physiotherapy diagnosis

Physiotherapy problem list

Treatment plan
Short term goal Date achieved:

Long term goal Date achieved: