GENERAL INFORMATION PMHx:

Name: _________________________________________________________ ___ HTN (Controlled / Uncontrolled) Since when: ____/____/____

Age: ______ Sex: ________ Civil Status: _________ Handedness: ___ DM (Controlled / Uncontrolled) Since when: ____/____/____
__________ ___ Cardiac Dse (Controlled / Uncontrolled) Since when: ____/____/____
Address: _______________________________________________________ ___ Lung Dse (Controlled / Uncontrolled) Since when: ____/____/____
Occupation: ____________________________________________________ ___ Stroke ___ Asthma ___ CA (Type: _____________)
Referring Unit: __________________________________________________
Referring Doctor: ________________________________________________ FMHx:
Date of Consultation: ______/______/_______ MATERNAL
Date of Referral: ______/______/______ ___ HTN ___ DM ___Cardiac Dse ___Lung Dse
Date of Initial Evaluation: ______/______/______ ___ Stroke ___ Asthma ___ CA (Type: _____________)

HPI PATERNAL
Present condition started when: ____________________________________ ___ HTN ___ DM ___Cardiac Dse ___Lung Dse
How did it happen: _______________________________________________ ___ Stroke ___ Asthma ___ CA (Type: _____________)
_______________________________________________________________
_______________________________________________________________ PSHx
Complaint: _____________________________________________________ (Smoker / Non Smoker) Sticks per day: _________ Years:
_______________________________________________________________ ______________
If pain: (Alcoholic / Non Alcoholic) Bottles per session: ____ Frequency:
Characteristic: ___________________________________________ __________
Location: ________________________________________________ ( Active / Sedentary) Activities: _____________________________________
Intensity: _______________________________________________ _______________________________________________________________
Alleviating Factor: ________________________________________ How many times a week: __________________________________________
Aggravating Factor: _______________________________________ Working: (YES / NO) Schedule of work: _______________________________
Initial Action after injury (rest, meds, first aid): Mode of transportation: ___________________________________________
________________________ Distance from house to work: _______________ Hours of travel:
_______________________________________________________________ __________
Effect of the said action: ___________________________________
Duration: _______________________________________________ HOME SITUATION
Reason for consult or referral: _____________________________________ Financial Capacity: _______________________________________________
Date or days prior to PTIE: ________________________________________ Living with: __________________ Children: (YES / NO) #: ________________
Diagnosis: _____________________________________________________ Who will shoulder bills and expenses: ________________________________
Procedure: ____________________________________________________
Ancillary Procedures: ____________________________________________ ENVIRONMENTAL ASSESSMENT
Physicians Order: _______________________________________________ Type of House: ____________________ No. of floors: ___________________
Medical Intervention: ____________________________________________ Having the main entrance as the pt of ref, the measurements were
Hospitalized: (YES / NO) How long: _________________________________ obtained:
PT during hospitalization: (YES / NO) Living Room: ~______ Kitchen: ~______ Bedroom: ~______
State present condition of pt before PT: _____________________________ Bathroom: ~______ ETC: __________________________________
______________________________________________________________ HEIGHT
Cabinet: ~______ Sink ~______ Bed Height: ~______
Light Switches: ~______ Door knobs: ~_____ ETC:______________
Flooring:_ ________________________________________(SKID / NONSKID)
Lighting: Well Lit (YES / NO)
WORK SUBJECTIVE
No. of floors: ___________________ Chief Complaint: _________________________________________________
Having the office as the pt of ref, the measurements were obtained: _______________________________________________________________
Pantry: ~______ Conference Room: ~______ Elevator: ~______ Pts Goal: _______________________________________________________
Bathroom: ~______ ETC: __________________________________ _______________________________________________________________
HEIGHT
Cabinet: ~______ Sink ~______ Bed Height: ~______
Light Switches: ~______ Door knobs: ~_____ ETC:______________ OBJECTIVE
Flooring:_ ________________________________________(SKID / NONSKID) VITAL SIGNS
Lighting: Well Lit (YES / NO) BP: _____/_____mmHg PR: _____bpm
RR: _____ cpm Temp: _____deg Celcius
ANCILLARY/LAB PROCEDURES
PROCEDURE DATE/HOSPITAL RESULTS OCULAR INSPECTION
Ambulatory: (YES / NO) Assistive Device: (YES / NO):
____________________
OR Level of Assist ________________________________________________
(Bedridden / Bedbound / Bedfast)
Level of Consciousness (Alert / Lethargic / Obtunded / Stupor / Coma)
Body Built (Ectomorph / Endomorph / Mesomorph)
Eye Deformities (Esotropia / Exotropia / Hypertropia / Hypotropia)
Drooling (YES / NO) ______ Minimal ______Mod ______Severe
At what position of the head: _______________________________
Aphasia (YES / NO) Facial Asymmetry (YES / NO)
Typical Arm Posture (YES/ NO)
Synergy/Deformity: ______________________________________________
Postural Deviation (YES / NO) Gait Deviation (YES / NO)
MEDICATIONS TAKEN Swelling (YES / NO) Location: _______________________________________
DRUG DOSAGE/FREQUE INDICATION Wounds (YES / NO) Location: _______________________________________
NCY Orthotics/ Prosthesis (YES / NO) Type: _______________________________
Attachments (Catheter / IV / Mech Vent) ETC: _________________________
Atrophy (YES / NO) Muscle: ________________________________________
Tropic Changes (Redness / Cyanosis) Location:
_________________________

PALPATION
Tenderness (YES / NO) Grade: ____ Location: __________________________
Skin Temperature: _______________________________________________
Edema (YES / NO) (PITTING / NON-PITTING) Grade: ____ Location:
________
Subluxation (YES / NO) Location: ____________________________________
Spasm (YES / NO) Muscle: _________________________________________
ROM SENSORY ASSESSMENT
JOINT / AROM PROM END FEEL STDs SENSATI UE LE
LATERALITY USED ON
R L R L
COTTO Light
N / Touch
BRUSH
THUMB Pressure
SHARP Pain
OBJ
Intact, Diminished, Increased, Decreased

DEEP SENSATION
TEST POSITI UE LE
MMT ON
Type of Muscle Testing Used: ______________________________________ R L R L
MUSCLE / GRADE MUSCLE / GRADE PROPRIOCEP
LATERALITY LATERALITY TION
KINESTHESIA

CORTICAL SENSATION
TEST OBJECT/LE UE LE
TTER
R L R L
STEROGN
FMT OSIS
Activity Grade BAROGNO
Hand to top of head SIS
Hand to mouth GRAPHES
Hand to opposite ear TESIA
Hand to opposite shoulder
Hand to opposite knee DTR
Heel to opposite toe
Heel to opposite shin
0 No response
Hell to opposite knee
+1 present but depressed
+2 normal
+3 increased
Legend: +4 hyperactivity with clonus
Functional (F) Normal
Weak Functional (WF) Moderate Impairment
Non-Functional (NF) Sever Impairment
No Function (NF) Cannot do activity
TONE ASSESSMENT (MAS) Grading:
4 N performance of movement
MUSCLE GRADE MUSCLE GRADE
3 Most is accomplished with only slight difficulty
2 Mod difficulty is demonstrated in accomplishing activity: movements are
arrythmitic and performance deteriorates with increasing speed
1 Severe difficultly is noted; movements are very arryhtmitic, significant
0 No Inc in tone 2 Marked inc through most of range unsteadiness, oscilations and/or extraneous movements are noted
1 Slight inc at the end range 3 Passive movement difficult 0 Unable to accomplish activity
1+ - Slight inc at <half of range 4 Rigid in flexion or extension SPECIAL TEST
PATHOLOGIC REFLEXES TEST L R TEST L R
Reflexes Procedure Response
Babinski Pin stroke up at the
lat. side of the foot
moving from the
heel to the base of
the little toe and POSTURAL ASSESSMENT
then across the ball (STANDING / SITTING / SUPINE / PRONE)
of the toe ANTERIOR LATERAL POSTERIOR
Chaddock Pin stroke up at the __ Head in __ Earlobe in line w/ __ Scapulae level
lat side of the foot Midline acromion process and Symmetry: _________
moving from the iliac crest Distance from midline:
heel to the base of __________________Wingi
the little toe ng
Abdominal Pin stroke over __ Shoulders __Chin pokes forward Spinous process
abdominals from level alignment:
periphery to __ L higher than __ Straight
umbilicus R __ Curved Laterally
CRANIAL NERVE TESTING __ R higher than
I Smell (Lemon, Coffee) L
II Snellens Chart/Confrontation Test __ Sternum in __ Shoulder in proper Ribs:
II/III Accommodation Reflex midline alignment
III/IV/V Nystagmus? Lid Droop? Restraction? Note: Size of pupil,
regularity and equality. __ Iliac crests __ Chest deformities __ PSIS Level
V Jaw Jerk/ Facial Sensation/ Strength of jaw in opening and closing level (CARNATUM /
V/VII Corneal Blink Reflex and facial muscle strength EXCAVATUM)
VIII Rinne / Weber __ ASIS Level __ Thoracic Kyposis __ Gluteal Folds Level
IX.X Gag Reflex
XI Strength of SCM and Trapezius __ Patellae level __ Lumbar Lordosis Achilles tendon /
XII Protrude the tongue and move rapidly side to side or alignment Calcaneus (VARUS /
COORDINATION TESTING VALGUS)
Equilibrium Test (GENU VALGUM / __ PSIS higher than
1. 2. VARUM) ASIS
3. 4.
Non Equilibrium Test Toeing (IN / OUT)
1. 2. (PES PLANUS /
3. 4. PES CAVUS /
NORMAL)
( PRONATED/
SUPINATED /
NORMAL)

GAIT ASSESSMENT FUNCTIONAL REACH TEST

STANCE TRUNK HIP KNEE ANKLE TRIAL 1 TRIAL 2 TRIAL 3
PHASE
A. Heel Average: _____
Strike
ROMBERGS TEST
B. Foot 1- Minimal Sway 3- Moderate Sway
Flat 2- Mild Sway 4- Loss of Balance
6MWT
TIME DISTANC BP HR BORGS
C. E SCALE
Midstance

D. Toe Off
ADLS
FIM
SWING TRUNK HIP KNEE ANKLE SELF-CARE GRA DESCRIPTION
PHASE DE
A. Initial 1. EATING
Swing 2. GROOMING
3. BATHING
B. 4. DRESSING UE
Midswing 5. DRESSING LE
6. TOILETING
7. SWALLOWING
C. SPINCHTERS GRA DESCRIPTION
Terminal DE
Swing 1. BLADDER
2. BOWEL
Base Width: ________ Step Length: ___________ MOBILITY GRA DESCRIPTION
Stride Length Cadence: _______________ DE
FUNCTIONAL ASSESMENT 1. TRANSFERS:
BALANCE AND TOLERANCE Bed/Chair/Wheelch
BALANCE TOLERANCE air
SITTING 2. TRANSFERS:
STANDING Toilet
N accepts challenge; >45mins F can maintain; 15-29mins
G can weight shift; 30-45mins P can assume; <15mins 3. TRANSFERS:
Shower
TIME UP AND GO 4. TRANSFERS: Car
TRIAL 1 TRIAL 2 TRIAL 3 5. LOCOMOTION:
Walking/
Average: _____ Wheelchair
6. LOCOMOTION:
Stairs
7. COMMUNITY
MOBILITY
TOTAL SCORE: ________

Legend;
No helper
7- Complete Independence (timely, safety)
6- Modified Independence
HELPER- MODIFIED INDEPENDENCE
5- Supervision ( Subject= 100%)
4- minimal Assistance ( Subject= 75%)
3- Moderate Assistance ( Subject= 50%)
HELPER-COMPLETE INDEPENDENCE
2- Maximal Assistance ( Subject= 25%)
1- Total Assistance or not testable ( Subject= <25%)
ANTROPOMETRIC MEASUREMENTS
LIMB GIRTH
LANDMARK L R
S Increased pain at wound site?
ENDURANCE
6MWT (LOOK AT FUNCTIONAL ASSESSMENT)
WOUND ASSESSMENT
Wound Stage: _______________
Characteristic: (NECROSIS / GRANULATION / INFECTION)
Location: ___________________
Exudate: (NONE / LOW / MODERATE / HIGH)
Odor: (ABSENT / PRESENT) Describe: _________________________________
Condition of Surrounding: (NORMAL / EDEMATOUS / WHITE / SHINY /
WARM / RED / DRY / SCALING / THIN / ETC: _______________ )
DIFFERENCE Delayed Healing?
In case of chronic wound pain
CLITAA

STUMP ASSESSMENT
MUSCLE BULK Level of Amputation: (SHORT/ MEDIUM / LONG)
LANDMARK L R DIFFERENCE Stump Shape: (CONICAL / CYLINDRICAL)
/ MUSCLE Distal Pressure Tolerance: (NONE / POOR / GOOD)
Flap: (ANTERIOR / POSTERIOR / FISH MOUTH)
CARDIAC ASSESSMENT Phantom Sensation (YES / NO)
Heart Rate: ____bpm Rhythm: ______________ Phantom Pain (YES / NO)
Auscultation: (Normal / Systolic Murmur / Diastolic Murmur /
Ventricular Gallop / Atrial Gallop / Pericardial Friction Rub / Bruit) ROM End Feel
Pulse: ____
PULMONARY ASSESSMENT Mushy
Auscultation: Muscle spasm
Breath Sounds: ( Vesicular, Bronchial, Bronchovesicular, Contracture
Crackles, Wheezes, Etc) Empty
Suprascapular: ____________________ Hard
Infrascapular: ____________________ Soft
 Interscapular: ____________________ Capsular tightness
Base of the Lungs: __________________ boggy

CHEST EXPANSION
LANDMARK AT REST INSPIRATIO DIFFERENCE
S N
AXILLA
T4
T10