Taral Patel

Name:
DOB:
Age:
Sex: M/F, Cis/ Trans
Medical Diagnosis:
Referring Physician:
Date:
PT Dx:
History of Current Problem:
What brings you in? ________________________ Date of Onset: ________________________
MOI: How long? _______________________________________________________________
Pain
Current: ____/ 10
At best: ____/ 10
At worst: ____/ 10
How would you describe your pain? (Circle all that apply)
Sharp Dull Burning Aching Tingling Numb Constant Radiating
Location (circle):
What aggravates it? ____________________________________
____________________________________________________
What relieves it? ______________________________________
____________________________________________________
Does it get worse at night? Yes/ No
Social/ Home History
Single _______ Married _______
Occupation: ________________ Limitations: Y/N
Physical Activities: _____________________________________________________________
Hobbies: ______________________________________________________________________
Use of Tobacco/ Drugs/ Alcohol:
Living Condition (Circle): Home/ Apt.
Stairs: Y/ N
Rails: Yes/ No
Difficulties with any transfers: Toilet: Y/ N Shower: Y/ N Bed: Y/ N Chair: Y/N Car: Y/N
Any difficulties inside home? Y/N please explain:
Assistive Devices/ Durable Medical Equipment:
Indoor: _______________________________________________________________________
Outdoor: ______________________________________________________________________
Long distance: _________________________________________________________________
Medical History
Do you take any prescription medications? Yes/ No If yes:
Medication (with Dosage & Frequency)
Do you have any allergies? Yes/ No If yes: ___________________________________________
Do you take any nonprescription medications or supplements? Yes/ No If yes: ______________
______________________________________________________________________________
Have you ever had surgery? Yes/ No
What/Where: __________________________________
Date: ______/ 20_____
What/Where: __________________________________
Date: ______/ 20_____
What/Where: __________________________________
Date: ______/ 20_____
Within the past year have you had any of the following medical tests? Date: ________________
MRI
Blood test
Bone scan
CT scan
Doppler ultrasound
EKG
Xray
Other: ________________________________________________________________________
Falls? Yes/ No (Recent/Previous)
Date:
Environment & Frequency: ____________________________________________
___________________________________________________________________
___________________________________________________________________
Signature: _______________________________

Date: ___________________________

Taral Patel
Hospitalization: Yes/ No
Reason of stay: _________________________________________
Vision/ Hearing correction? Yes/ No
Mental Examination: Spontaneously opens eyes Converse appropriately Follows verbal requests
Oriented to Person (self, others) Oriented to place (state, town, building)
Oriented to time (day, time, month, year) Native language:
Other:
Other Medical Complications:

Past Medical History (Check all that apply): NONE of the below
Heart attack (MI)
Angina
Congestive Heart Failure
Mitral Valve Prolapse
High Blood Pressure
High Cholesterol/ triglycerides
Heart disease
Arrhythmia
Anemia
Stroke
Bleeding disorder
Blood clots in lung (PE)
Blood clots in extremities (DVT)
Peripheral vascular disease
Peripheral neuropathy
Cancer, Type:

Lung disease
Asthma
Emphysema
Pneumonia
Chronic bronchitis
Reaction to anesthesia
Kidney stones/ disease
Tuberculosis
Hiatal Hernia
Reflux
Stomach or intestinal ulcers
Peptic ulcer disease
Crohns disease
Ulcerative colitis
Irritable bowel
Diverticulitis
Osteoarthritis

Systems Review:
Musculoskeletal: decr balance, coordination, fatigue,
numbness, joint pain

Hematologic: rapid pulse or bleeding from nose

Genitourinary: less urination or pain w/ urination
Rheumatologic: muscle pain or weakness
Cardiovascular: chest pain or palpitations
Diabetes mellitus: polyuria, polydipsia
Gastrointestinal: bowel, diarrhea/constipation
Inter-professional team (also seeing):

Rheumatoid arthritis
Osteoporosis
Hepatitis
Liver problems
Diabetesinsulin dependent? Y/N
Thyroid disease
Urologic problems
Stress incontinence
Enlarged prostate
Frequent urinary tract infections
Psychiatric history
Anxiety
Depression
Schizophrenia
Headaches
HIV +ve
Other:

Immunologic: change in skin, sleep problems

Endocrine: change in weight, hot flashes
Hepatic/ Biliary: change in taste or smell
Psychology: rashes or recent skin changes
Pulmonary: shortness of breath, cough up blood
Cancer: loss of appetite or unexpected weight loss
Gynecologic: bleeding or menstrual cycle pain
Psychological: depressed, mood & memory

Medical measures & Vitals

Anthropometric characteristics:
Height: ___________________________ Weight: ___________________________________
Limb length measurements: _______________________________________________________
Circumferential measurements: ____________________________________________________
Aerobic capacities/ Endurance:
Cycle test: _________________________ Treadmill test: ______________________________
10M Shuttle test: ____________________ 6-MWT: __________________________________
Circulation (Arterial, Venous, Lymphatic) & Ventilation and Respiratory/ Gas Exchange:
ABI: ______________________________ Blood Pressure: ________ / ___________
Pulse: Quantity: ________ Grade: _______
Location: _____________________________
Allens Test: _______________________ Homans Sign: _____________________________
Trendelenburg Test: ___________________ Percussion Test: ___________________________
Spirometer reading: _____________________________________________________________
______________________________________________________________________________
Signature: _______________________________

Date: ___________________________

Taral Patel
Integumentary Integrity:
Observation and Palpation: _______________________________________________________
Trophic changes (Fibrosis, coloration, temperature): ___________________________________
______________________________________________________________________________
Wounds Size and Depth: _________________________________________________________
Pressure stage: _________________________ Braden Scale: ____________________________
Drainage (amount and description): _________________________________________________
Sensory testing:
Sensation
Findings (L/R, 0= absent, 1= impaired, 2= intact)
Superficial

Light touch
Pressure
Pain
Temperature
Deep

Proprioception
Kinesthesia
Vibration
Cortical

Graphesthesia
Sterognosis
Barognosis
Muscle Groups

MMT*

ROM

Tone**

* MMT is typically:
0: absent
1: trace, flicker
1+: < 50% ROM gravity min
2-: gravity min > 50%
2: gravity min no resistance
2+: gravity min w/ resist. Or agst
grav <50% ROM
3-: agst grav 100%-50% ROM
3: no resist, full ROM, agst grav
3+: with resistance give quick
4: with resistance little give
5: with max resistance

** Tone is according to
Modified Ashworth Scale
0: No incr in tone
1: Slight incr, catch and
release at end range
1+: Slight incr, catch with min
resistance < ROM
2: Incr ms tone thru ROM
3: Incr ms tone affecting
passive ROM
4: Incr ms tone affect active
ROM
L

Signature: _______________________________

R
Date: ___________________________

Taral Patel
Shoulder elevation
Shoulder flexion
Shoulder ABD
Shoulder IR
Shoulder ER
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
Finger flexion
Finger extension
Hip flexion
Hip extensors
Hip ABD
Hip ADD
Hip IR
Hip ER
Knee flexion
Knee extension
DF
PF
Coordination Assessment:
Skill: non-Equilibrium

/180

/180

/180
/70
/90
/150
/0
/80
/70

/180
/70
/90
/150
/0
/80
/70

/120
/20
/40
/20
/45
/45
/150
/<10
/20
/50

/120
/20
/40
/20
/45
/45
/150
/<10
/20
/50

L R Notes: (for 5x)

Coordination- Balance: Gross

Berg Balance Scale Notes:
____ /56
DGI/ FGA
Notes:
TUG > 14 sec
FSST
Other: _______
Vestibular tests

Finger to nose
Heel to shin
Skill: Equilibrium
Seconds
Tandem gait
Rhomberg test
SOT/ mCTSIB
Reciprocal Mvmts
Symmetry
Speed
Fatigue?
Upper Extremities
Lower Extremities
Motor Assessment
Left
Right
Tremors
Present
Absent
Present
Absent
Involuntary/ Uncontrolled mvmt Present
Absent
Present
Absent
Muscle atrophy
Present
Absent
Present
Absent
Width
of
base
Score
FIM Scale
1. Transfers
No Helper
L 7 Complete Independence (Timely &
a. Bed, Chair, Wheelchair
Safely)
E
b. Toilet
V 6 Modified Independence (Devices)
c. Tub, Shower
2.
Locomotion
E Modified dependence
Helper
a. Walk
L 5 Supervision (Pt= 100%)
b. Wheelchair
4 Minimal Assist (Pt= 75%)
3 Moderate Assist (Pt= 50%)
Complete dependence
2 Maximal Assist (Pt =25%)
1 Total Assist (Pt <25%)

3.

c. Stairs
Social/Cognition
a. Memory
b. Problem Solving

Signature: _______________________________

Date: ___________________________

Taral Patel
Cranial Nerve Integrity
Upright Motor Scale: R/L
(Intact, Impaired, Absent) (Left, Right)
CN I
Hip Flexion
W M S
Hip Extension W M S
CN II
CN III
Knee Flexion
W M S
Knee
Extension
W M S E UT
CN IV
CN V
Dorsiflex
W S
Plantarflex
W M S E UT
CN VI
CN VII
* For UMC:
W = weak
CN VIII
M = moderate
CN IX
S = strong
CN X
E = excessive
CN XI
UT = unable to test
CN XII
Reflex Integrity
Deep Tendon Reflexes (0, 1+, 2+, 3+, 4+, C= Clonus with __ B for beats, R= Right/ L= Left)
Jaw (CN V)
Biceps/ Musculocutaneous n (C5,C6)
Brachioradialis/ Radial n. (C5,C6)
Triceps/ Radial n. (C6, C7)
Finger flexors/ Median n. (C6-T1)
Hamstrings/ Tibial branch of Sciatic
n. (L5, S1, S2))
Quadriceps/ Femoral n. (L2, L3, L4)
Achilles/ Tibial n. (S1-S2)
Superficial Cutaneous Reflexes
Plantar (S1, S2)
Abdominal Reflex: (T10)
Below umbilicus
Above umbilicus
Primitive & Tonic Reflexes
Flexor withdrawal
Crossed Extension
Traction
Moro
Startle
Grasp
ATNR
STNR
Positive supporting
Associated reactions
Postural Analysis
Sitting:
Standing:
Other:
Activity-Based Task Analysis
Weight Shift:

Mid-phase:

Initial Lift:

Final position:
Signature: _______________________________

Date: ___________________________

Taral Patel
GaitReference point: Left/ Right
Cadence:
Stride length:
Deviation
Trunk

Details: Phase, L/R

Lean
Lateral Lean
Rotates
Pelvis
Hikes
Tilt
Lacks fwd rotation
Lacks bkwd rotation
Excess fwd rotation
Excess bkwd rotation
Ipsilateral drop
Contralateral drop
Hip
Flexion limited
Excess
Past Retract
Rotation: IR/ER
AD/ABDuction
Additional Notes/ Comments:

Walking Base:
Deviation
Details: Phase, L/R
Knee
Flexion limited
Excess
Wobbles
Hyperextends
Extension thrust
Valgus/ Varus
Excess contralateral flex
Ankle Forefoot contact
Flat contact
Heel off
No Heel off
Drag
Contralateral vaulting
Toes
Up
Inadequate Extension
Clawed/ Hammered

Assessment & Goals:

Practice Pattern: ___________________________

Patient Goals: __________________________________

Problem List:

______________________________________________

3.
4.
5.
6.

PT Short Term Goals: ____________________________

______________________________________________

Intervention with CPT codes:

______________________________________________
______________________________________________

1.
2.
3.
4.

______________________________________________
PT Long Term Goals: ____________________________

Prognosis: ________________________________

______________________________________________

_________________________________________
Signature: _______________________________

Date: ___________________________

Taral Patel
______________________________________________
______________________________________________
______________________________________________
Referral to:

For filing purposes only:

Documentation: Patient name:
Physician:

DOB:
Evaluation

Age:

MD Diagnosis:

PT Diagnosis with Practice pattern

Onset

Prognosis & POC:

Examination: History, systems review, test, measures

Intervention with CPT codes:

Signature: _______________________________

Date: ___________________________