INITIAL EVALUATION

GENERAL INFORMATION
Pt.’s Name: Indicate the patient’s initial only for privacy.
Age: (Sig.: Some conditions are age-related)
Sex: (Sig.: Some conditions are more prevalent according to gender)
Address: (Sig.: Proximity to the clinic; Capability of the patient to comply with the treatment sessions)
Civil Status:
Handedness: (Sig.: Laterality of patient’s condition if applicable)
Occupation: Full time/Part time; Inside/Outside work; Retired; Student
Referring Doctor:
Referring Unit:
Rehab Doctor:
Date of Referral:
Date of Consultation/Admission:
Date of IE:
Diagnosis:
(Optional)
Height/ Weight: Commonly used in musculoskeletal conditions
Informant: If the patient can’t speak for himself. Ex: pediatric patient, mental affectation

SUBJECTIVE:
A. Chief Complaints (c/c):
If due to pain: frequency, type of pain, pain scale, location of pain, aggravating factor, relieving factor

Pain Descriptions and Related Structures

Type of Pain Structure
Cramping, dull aching Muscle
Dull, aching Ligament, joint capsule
Sharp, hooting Nerve root
Sharp, bright, lightning-like Nerve
Burning, pressure-like, stinging, aching Sympathetic nerve
Deep, nagging, dull Bone
Sharp, severe, intolerable Fracture
Throbbing, diffuse Vasculature

B. Prior Level of Function: This describes the patient’s level of function prior t the most recent onset of his current condition or complaints. If
the patient has a chronic condition, this includes level of function prior to the most recent onset symptoms or exacerbation of his/her
condition.

C. Patient’s Goal: If patient can’t speak, family or caregiver can set the goals for therapy.

D. History of Present Illness:

Possible questions to ask the patient: (example: musculoskeletal condition)
• Why has the patient come for help?
• Was the onset of the problem slow or sudden?
• Where are the symptoms that bother the patient?
• Where was the pain or other symptoms when the patient first had the complaint?
• What are the exact movements or activities that cause pain?
• Are the intensity, duration, or frequency of pain or other symptoms increasing?
• What type of pain is exhibited?

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 E. Past Medical History:
(-/+) HTN
(-/+) DM
(-/+) CVA
(-/+) Heart Condition
(-/+) Pulmo Condition
(-/+) Trauma

F. Familial medical History:

Mother Father
HTN (-/+) (-/+)
DM
CVA
Heart Condition
Pulmo Condition
Trauma

G. Personal/Social History:
• Type of Personality
• Diet:
• Cigarette Use: (No. of packs per day x Years smoking)= packyears
• Alcoholic Beverage Consumption:
o Type of Alcoholic Beverage
o Frequency:

H. Home/ Work/ School Situation:

Upper extremity: measure the area of work place
Lower extremity: steps of stair, distance from 1 room to another, home to work travel

I. Laboratory Procedure:
Date Laboratory Test Results

Findings:
Significance:

J. Medications:
Medication Dosage Frequency Indication

OBJECTIVE:
A. Vital Signs
Resp. Rate Heart Rate Diastolic BP Systolic BP Temperature
Age Group (Breathes per min.)
(Beats per min.) (mmHg) (mmHg) (°C)
(Cycle per min.)
Newborn 30-50 120-160 Varies 50-70 36.5
Infant (1-12mos) 20-30 80-140 Varies 70-100 37.0
Toddler (1-3 yrs) 20-30 80-130 48-80 80-100 37.0
Preschooler (3-5 yrs) 20-30 80-120 48-80 80-100 37.0
School age (6-12 yrs) 20-30 70-110 50-90 80-100 37.0
Adolescent (13-17 yrs) 12-20 55-105 60-92 110-120 37.0
Adult (18+ yrs) 18-20 60-100 <85 <130 37.0
Remember these points:
The patient’s normal range should always be taken into consideration.
HR, BP, and RR are expected to increase during times of fever or stress.
Respiratory rate for infants should be counted for a full 60 seconds.
BP: mmHg (millimeter mercury)
RR: bpm/cpm (breaths/cycle per minute)
PR: bpm (beats per minute)
Temp: °C/°F (degree Celsius/Fahrenheit)

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 Magnitude of Hypertension
Mild Moderate Severe Very severe
Normal
Stage 1 Stage 2 Stage 3 Stage 4
Child (6-9 years)
Systolic 80-120 120-124 125-129 130-139 ≥140
Diastolic 50-75 75-79 80-84 85-89 ≥90
Child (10-12 years)
Systolic 80-120 125-129 130-134 135-144 ≥145
Diastolic 50-80 80-84 85-89 90-94 ≥95
Adolescent (13-15 years)
Systolic 110-120 135-139 140-149 150-159 ≥160
Diastolic 60-85 85-89 90-94 95-99 ≥100
Adolescent (16-18 years)
Systolic 110-120 140-149 150-159 160-179 ≥180
Diastolic 60-90 90-94 95-99 100-109 ≥110
Adult (>18 years)
Systolic 110-130 140-159 160-179 180-209 ≥210
Diastolic 80-90 90-99 100-109 110-119 ≥120
Magee (2010): Clinical implications of the AHA preparticipation cardiovascular screening guideline, Athletic Ther Today 5(4):55, 2000.

B. Ocular Inspection
• Ambulatory capabilities
o Bedridden: Can’t move around bed
o Bedbound: Able to turn inside the bed
o Bedfast: Able to go to bathroom or walk around the room
o Wheelchair-borne: patient can’t walk and mode of transport is wheelchair
o Mother-borne: patient can’t walk and mode of transport is by carrying around by mother
o Ambulatory with: assistive device used
o Ambulatory without assistive device
o Ambulatory +1 assist
• Level of Consciousness
o Alert: can carry normal conversation, w/ no delays & is aware of time/place /identify
o Lethargic: confused & disoriented to time, place or identity; difficulty following commands
o Obtunded: appears drowsy & lethargic but readily replies to verbal stimulation if questions are simple
o Stupurous: respond are elicited only in response to loud noise or painful stimulation
o Comatose: appears to be sleep does not respond to painful stimulation
• Body Built
o Mesomorph: Muscular, prominence of structures from mesoderm
o Ectomorph: thin, prominence of structures from ectoderm
o Endomorph: heavy, ft built, prominence of structures from endoderm

• (+) Obvious Physical Findings

o Swelling
o Deformity
o Atrophy/ Hypertrophy
o Skin discoloration
o Wounds/scars

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 o Erythema
o Asymmetry
o Gait deviation
o Postural deviation
• (-) Pertinent findings

C. Palpation
• Thermicity
o Hyperthermic
o Normothermic
o Hypothermic
• Tonicity
o Hypertonic
o Normotonic
o Hypotonic
• Inflammation
• Subluxation: measure by fingerbreadths
• Tenderness (Grading/Location)
o Grade 1: complains of pain
o Grade 2: complains of pain and winces
o Grade 3: winces and withdraws limb
o Grade 4: patient won’t allow palpation
• Edema
o Grading of depression: Pitting/Non-pitting
▪ Mild 1+ : < ¼ inch of depression
▪ Moderate 2+ : ¼ - ½ inch depth of depression
▪ Severe 3+ : ½ - 1 inch of depression
o Grading
• Muscle guarding/ spasm/ splinting

D. Neurological Evaluation
a. Level of Consciousness
• Arousal: the stimulation to action or to physiologic readiness for activity
• Mentation: a mechanism of thought or mental activity
• Cognition: the act or process of knowing, including both awareness and judgment
b. Superficial Sensory Testing
• Light touch, pain, pressure
Findings:
Significance:

c. Deep Sensory Testing

• Kinesthesia
• Proprioception
• Graphestesia
• Stereognosis
Findings:
Significance:

d. Reflex Testing
• DTR/MSR
o Jaw (trigeminal) LEGEND:
o Biceps (C5,C6) 0- Absent
o Triceps (C7,C8) 1- Diminished (hyporeflexia)
o Hamstrings (L5, S1,S2) 2- Average (normal)
3- Exaggerated (brisk)
o Patellar (L2,L3,L4) 4- Clonus, very brisk (hyperreflexia)
o Ankle (S1,S2)

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 Pertinent Central Nervous
Reflex Site of Stimulus Normal Response
System Segment
Jaw Mandible Mouth closes Cranial nerve V
Biceps Biceps tendon Biceps contraction C5-C6
Brachioradialis Brachioradialis tendon or distal to Flexion of elbow and/or pronation
C5-C6
the musculotendinous junction of forearm
Triceps Distal triceps tendon above the Elbow extension/muscle
C7-C8
olecranon process contraction
Patella Patellar tendon Leg extension L3-L4
Medial hamstrings Semimembranosus tendon Knee flexion/muscle contraction L5,S1
Lateral Biceps femoris tendon Knee flexion/muscle contraction
S1-S2
hamstrings
Tibialis posterior Tibialis posterior tendon behind Plantarflexion of foot with
L4-L5
medial malleolus inversion
Achilles Achilles tendon Plantar flexion of foot S1-S2

Findings:
Significance:

• Superficial Cutaneous reflex

Pertinent Central Nervous
Reflex Normal Response
System Segment
Upper abdominal Umbilicus moves up and toward area being stroked T7-T9
Lower abdominal Umbilicus moves down and toward area being stroked T11-T12
Cremasteric Scrotum elevates T12,L1
Plantar S1-S2
Gluteal Skin tenses in gluteal area L4-L5,S1-S3
Anal Contraction of anal sphincter muscles S2-S4

• Pathological Reflex
Reflex Elicitation Positive Response
Babinski Stroking of lateral aspect of Extension of big toe and Pyramidal tract lesion
sole of foot fanning of four small toes
Normal reaction in Organic hemiplegia
newborns
Chaddock’s Stroking of lateral side of Same response as above Pyramidal tract lesion
foot beneath lateral
malleolus
Oppenheim’s Stroking of anteromedial Same response as above Pyramidal tract lesion
tibial surface
Gordon’s Squeezing of calf muscles Same response as above Pyramidal tract lesion
firmly
Piotrowki’s Percussion of tibialis Dorsiflexion and supination Organic disease of central
anterior muscle of foot nervous system
Brudzinski’s Passive flexion of one lower Similar movement occurs in Meningitis
limb opposite limb
Hoffman’s (Digital) “flicking” of terminal phalanx Reflex flexion of distal Pyramidal tract lesion
of index middle, or ring phalanx of thumb and of
finger distal phalanx of index or
middle finger
Rossolimo’s Tapping of the plantar Plantar flexion or toes Pyramidal hemiplegia
surface of toes
Schaeffer’s Pinching of Achilles tenson Flexion of foot and toes Organic hemiplegia
in middle third
Bilateral positive response indicates an upper motor neuron lesion. Unilateral response may indicate a lower motor neuron lesion.

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 o Primitive
o Developmental
e. Cranial nerve testing
Findings:
Significance:

f. Motor Control Assessment

• Tone Assessment
o Modified Ashworth Scale
▪ 0 : No increase in muscle tone
▪ 1 : slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of
the ROM when the affected parts is moved in flexion or extension
▪ 1+ : slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the
remainder (less than half) of the ROM
▪ 2 : more marked increase in muscle tone through mist of the Rom, but affected parts easily moved
▪ 3 : considerable increase in muscle tone, passive movement difficult
▪ 4 : affected pats rigid in flexion or extension
• Balance and Coordinaton
o Balance
Functional Balance Grades
Normal Patient is able to maintain steady balance without support (static)
Accepts manimal challenge and can shift weight in all directions (dynamic)
Good Patient is able to maintain balance without support (static).
Accepts moderate challenge; able to maintain balance while picking object
off floor (dynamic)
Fair Patient is able to maintain balance with hand hold (static)
Accepts minimal challenge; able to maintain balance while turning
head/trunk (dynamic)
Poor Patient requires handhold and assistance (static)

o Coordination
▪ Equilibrium Test
▪ Non-equilibrium Test

E. Range of Motion
All major joints of both upper extremity and lower extremity are within normal limit actively and passively done pain free, except
for:
Left Right
Endfeel Diff. Passive Active Joint Active Passive Diff. End feel
(normal)

Findings:
Significance:

F. Manual Muscle Testing

All major muscles of both upper extremity and lower extremity are grossly graded 5/5, except for:
Muscle/Movement Left Right

Findings:
Significance:

G. Special Test
Name of special test:
Result:
Significance:

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H. Anthropometric Measurement
• Limb Girth Measurement
Landmark Left Right Difference
Landmark should be placed in a prominent
bony area.
Measure 1 inch above the landmark. Measure in centimetre in every “inch”
Add additional inches until you measured landmark.
about 2 inches above the edematous area.
Same procedure below the landmark.
Example:
Landmark Left Right Difference
2 inches above Medial epicondyle of
13 14 1
humerus
1 inch above Medial epicondyle of humerus 13 15.5 1.5
Medial epicondyle of humerus 14 16 2
1 inch below Medial epicondyle of humerus 13 15.5 1.5
2 inches below Medial epicondyle of
13 14 1
humerus
Findings: Swelling on (R) elbow area
Significance:

• Muscle Bulk Measurement

Landmark Left Right Difference
Look for a bony landmark that is nearest the
bulk of the muscle
Look for the bulkiest portion of the muscle
and measure in inches the distance
between the two.
Measure the bulk of the muscle (centimetre).
Example:
Landmark Left Right Difference
4 inches above Medial epicondyle of
25 20 0
humerus
Finding:
Significant:

• Volumetric Measurement

• Leg Length Measurement

o True Leg Length
o Apparent Leg Length
o Segmental

• Stump Measurement

I. Wound Evaluation

J. Pulmonary Evaluation
• Breathing Pattern
• Chest Expansion Measurement
• Chest Expansion Symmetry
• Auscultation
• Tactile Fremitus
• Percussion

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 K. Postural Analysis

L. Gait Analysis

M. Functional Mobility
• Gross Motor
o Bed Mobility
o Transitional Mov’t
▪ Turning/Sidelying
▪ Supine ↔ Sitting
▪ Sitting ↔ Standing
o Standing
o Ascending & Descending Stairs
o W/C Mobility
▪ Transfers
▪ Propulsion
• Fine Motor
o Power & Precision Grip

N. Activities of Daily Living/ Outcome Measurement

• Activities of Daily Living
• Instrumental Activities of Daily Living

ASSESSMENT:
A. PT Diagnosis:
APTA Guide to Physical Therapist Practice
B. PT Impression
C. Rehabilitation Potential:
D. Prognosis:
E. Problem List:
F. Long Term Goal:
G. Short Term Goal:

PLAN:
A. Prescribed PT Management
B. Suggested PT Management
C. Home/Ward Instruction

__________________________
Signature over Printed Name

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