Initial Evaluation
Demographic Information:
Patient’s Name:
Address:
Age:
Date of birth:
Civil Status:
Dominant hand:
Sex:
Race:
Ethnicity:
Religion:
Occupation:
Date of admission:
Referring Doctor:
Date of referral:
Rehab/Attending doctor:
Medical Diagnosis:
/S/:
C/C:
HPI:
Functional Hx:
Social Hx:
Cultural and Religious Belief:
Family and Caregiver resources:
Financial support:
Employment/Work
Prior work:
Current work:
Living environment
General Health Status: (circle one if applicable)
I would rate my health as
Excellent
Good
Fair
Poor
Yes
No
Yes
No
Do you have any sores that have not
healed or any changes in size, shape, or
color of a wart or mole?
Have you had any unexplained weight
gain or loss in the last month?
Have you experienced any of the following?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1. Blood in urine, stool, vomit, mucus
2. Dizziness, fainting, blackouts
3. Fever, chills, sweats (day or night)
4.
Nausea, vomiting, loss of
appetite
5. Changes in bowel or bladder
6. Skin rash or other skin changes
7. Heart palpitations or fluttering
8. Numbness or tingling
9. Problems seeing or hearing
Yes
No
11. Joint pain
Yes
No
12. Memory loss
Yes
No
13. Sudden weakness
Yes
No
14. Trouble sleeping
Yes
No
15. Cough, dyspnea
Yes
No
10. Unusual fatigue, drowsiness
Yes
No
Yes
No
16. Throbbing sensation/pain in
belly or anywhere else
17. Headaches
What number would you
assign to your level of stress today? (On
a scale from 0 to 10, with 0 being no
stress and 10 being the most extreme
stress you have ever experienced)
Social/Health habits
Diet:
Allergies
coffee drinker:
soda drinker:
milk drinker
Alcohol and Drugs:
alcoholic beverage:
smoker:
substance abuse:
Family Health Hx:
Condition
Heart disease
Hypertension
Stroke
Diabetes Mellitus
Cancer
Psychological conditions
Arthritis
Osteoporosis
Maternal
Paternal
Patient
Medical/Surgical Hx:
Condition/Surgery
Date
Hospital
Medications:
Indication
Medication
Adverse Effects
Dosage/
Frequency
Other clinical tests:
Procedure
Taken (When & Where)
Results
Pt.’s Goals:
/O/:
OI:
Palpation
Systems Review
●
Cardiovascular/Pulmonary System: Vital signs:
ā tx
During tx
p̄ tx
Normal
BP
(mmHg)
R or L brachial artery, auscultatory
120/80
PR(bpm)
R or L radial artery, palpatory or
pulse oximeter
60-100
RR(cpm
Diaphragmatic or Chest (Thoracic)
12-20
T (⁰C)
R or L Axilla
36.1-37.2
O2 Sat
R or L index finger, pulse oximeter
95-100%
●
●
Integumentary System:
●
Neuromuscular System:
Gait:
Locomotion:
Balance:
Motor function:
●
●
●
●
Communication:
●




●
●
Musculoskeletal System:
Gross symmetry:
Gross range of motion:
Gross muscle strength:
Affect:
Emotional/behavioral responses
Cognition:
Level of consciousness:
Orientation to person, place & time:
Learning Barriers:
Vision:
Hearing problems:
Reading problems:
Language barriers:
Learning Style:
Education Needs:
Neurological Assessment
1. MMSE:
2. Arousal:
3. Orientation:
Cranial Nerve Testing:
Cranial Nerve
Tests
CN1 – Olfactory Nerve
Ask patient to identify non
noxious odors
CN2 – Optic Nerve
Snellen chart
Ask patient to cover one eye and
state how many fingers of the PT
they see
CN3 – Oculomotor
Nerve
CN4 – Trochlear
Nerve
CN6 – Abducens
Nerve
Pupillary light reflex (test
CN3)
CN5 – Trigeminal Nerve
Corneal reflex
Sensory tests of face (light touch)
Open and close jaw against
resistance Jaw jerk
reflex. Palpate temporal
and masseter muscles
Ability of eyes to follow a
moving target without head
movement
Findings
CN7 – Facial Nerve
Do facial movements:
✔
✔
✔
✔
✔
✔
Raise eyebrows
Frown
Wrinkle nose
Eye close
Smile, show top teeth
Lips purse✔
Compress cheeks against teeth
Identify different tastes
(using anterior tongue)
CN8 –
Vestibulocochlear
Nerve
Weber Test (on top/center of
head)
Rinne Test (bone and air
conduction)
CN9 –
Glossopharyngeal
Nerve
Examine taste on posterior
one-third of tongue
Examine gag reflex.
CN10 – Vagus Nerve
(supplies the
palatoglossus)
CN11 – Spinal Accessory
Nerve
CN12 – Hypoglossal Nerve
Sig:
Examine swallowing (drink
water/eat food); observe
uvula and soft palate
for any asymmetry
(tongue depressor).
Examine strength of the
SCM
and trapezius muscles.
With tongue protruded,
examine ability to move the
tongue rapidly from side to
side.
Sensory Evaluation:
***Grading:
0- absent, 1 - impaired, 2 - normal Superficial
Sensations:
Area
Tested
Pinprick
R
L
Light Touch
R
Deep Pressure
L
R
L
Face
C2-C8
L2-S2
Sig:
Deep Sensations
Modality
Right
UE
LE
Left
UE
LE
Kinesthesia
Proprioception
Vibration
Sig:
Cortical Sensations:
Modality
Right
UE
LE
Barognosis
Stereognosis
Sig:
Motor Function Assessment Tone
Assessment: Grading
1
slight increase muscle with catch at end of ROM
Left
UE
LE
1+
2
3
4
Slight increase in muscle tone
More marked increase in muscle tone
considerable increase in muscle tone
affected parts rigid in flexion or extension
Muscle Groups
Grade
Wrist Flexors
Wrist Extensors
Elbow Flexors
Elbow Extensors
Shoulder Flexors
Shoulder Horizontal Abductors
Shoulder Horizontal Adductors
Shoulder Abductors
Sig:
Reflex Assessment:
***DTR Grading
0 -Absent, 1- Diminished , 2- Average, 3-Exaggerated, 4- Clonus
Muscle Groups
Grade
Biceps
2+
Triceps
2+
Brachioradialis
2+
Patellar
2+
Achilles
2+
Sig:
Pathologic Reflexes
Result
Babinski Test
Sig:
Coordination Assessment: ***
Grading
4- Normal , 3- Minimal Impairment, 2- Moderate Impairment, 1- Severe impairment
Grade (L)
Coordination Test
Grade (R)
Finger - to - Nose
Finger - to - Finger
Finger - to - Therapist’s Finger
Sig:
Balance/Tolerance Assessment: Berg Balance Scale
Activity
Sitting to Standing
Standing Unsupported
Sitting with Back Unsupported but feet supported on
floor
Standing to sitting
Transfers
Standing unsupported with eyes closed
Standing unsupported with feet together
Reaching forward with outstretched arm while standing
Score
Pick up object from the floor from a standing position
Turning to look behind over left and right shoulder while
standing
Turn 360 degrees
Placing alternate foot on step or stool while standing
unsupported
Standing unsupported one foot in front
Standing on one leg
Total
Sig : Pt. acquires a score <45 et presents c̅ greater risk of falling 2 UMNL
Overall Motor Function Significance: Pt is hypertonic on R UE 2 U; severe impairment on coordination et balance;
no significance noted on reflex assessment.
ROM:
All major joints of the body are actively et passively assessed and found to be WNL, pain-free and c N end-feel,
Except:
Joint motion
AROM
PROM
Normal
Difference
AROM
® SH Fl
0-180°
® SH IR
0-70°
® SH ER
0-90°
® Elbow Fl
0-150°
® Wrist Ex
0-70°
PROM
End-feel
® Wrist Flex
0-80°
® Knee Fl
0-150°
® Ankle Dorsi
0-20°
® Ankle
Plantar
0-50°
SLR
0-90°
Sig:
MMT/FMT:
***Grading
Muscle Groups
® Sh Fl
® Sh IR
® Sh ER
® Elbow Fl
® Wrist Ex
® Wrist Fl
® Knee Fl
® Knee Ex
® Ankle Dorsiflex
® Ankle Plantarflex
® Hip Fl
Sig:
Grade
Overall Musculoskeletal Significance:
Postural Analysis:
Anterior/ Posterior
Lateral
Head and Face
Cervical spine (neck)
Trunk
Upper extremity
Hip and Pelvis
Knee and Thigh
Lower leg, ankle, and foot
Sig:
Gait Analysis:
(See RLA Observational Gait Analysis form)
Findings:
Functional Independence Measure:
(See Functional Independence Measure form)
to a healthy and active lifestyle to support his children; full recovery is not attainable d/t location of stroke.