Neurological Physiotherapy Evaluation Form

Client Name: ...... Job: ........

Age: ...... File. No: ....

Marital Status: .... Gender: ..........

Mobile. No: ...... Telephone. No:..........

Days of visit: ..... , ...... , ..... , ..... , ...... .

Frequency of visits/ Week: .

Time of session: ..........

Diagnosis:

Chief complaint:

Present History:
Onset:

Course:

Duration:
Radiological & Laboratory findings:

Past History:

Medical History:

Cardiac Anesthetics
Hypertension Analgesics
Hypotension Other
Diabetes

Family History:

General examination:
Level of consciousness .
Orientation ..
Gait problems ..
Involuntary movements ..
Assistive aids
Regional examination:
Observatory findings ..

..

..

Facial muscles affection ..

..

Palpatory findings ..

..

..

Motor affection ....

....

....

Sensory affection .....

Reflexes

Pain Assessment:

Aggravity factors:

Relieving factors:

Referred pain:
Coordination, proprioceptive& balance assessment findings:

Non Equilibrium tests Rt. Lt. Equilibrium tests Findings

Finger to nose 1- Dynamic:
Heel to knee . Walking.

. Standing with moving trunk or upper limbs.

. Sitting.
2- Static:
. Standing with bilateral support (Romberg test).

. Standing with unilateral support.

. Sitting with back and foot support.

. Sitting without back support.

Hand functions:
functional weak functional Non functional
1 Reaching
2 Grasping
3 In hand manipulation
4 Releasing
5 Hand to hand manipulation

Rom Assessment findings:

Muscle power assessment findings:

Problem list:

Short term goals:

Long term goals:

Plan of treatment:

Home program & advices (if required):

Signature
Date of Re-assessment:../../...

Progression:

New findings:

Signature