PATIENTS INFORMATION

I.History Taking
Date:
Age

Name:
Address:
Marital status:

Single (

Time:
Sex
(M)

(F)
Refering Physician:
Religion:
Birth Date:

Married ( )

mm / dd / yy
Separated (

Widow ( )
Occupation:
BP:
HR:
Ht:
Handedness
R (
(

Nationality:
RR:
PR:
Wt:
Educational Attainment
)

Chief Complaint:
History of Present Illness:

Present Medical Conditions:

Current Medications:

Allergies:

Past Medical History:

Race:
Temp:
LMP:
BMI:

Remarks:
Elementary (

HS (

Vocational

College (

Masteral

none (

Previous Hospitalizations:

Surgeries:

Injuries, Accidents, Disabilities:

Family History:

Asthma (

MI (

Hreart Failure (

diseases (

CA (

Diabetes (

TB (

Hypertension (

Social History
Lifestyle
Daily Activities: _____________
Habits: _____________
Exercise: _____________
Diet: _____________
Household
situation:_____________
Significant Relationships:_
________

Remarks:

)
)

Kidney
Hemophilia

Remarks:

Sexual History
Active (

Birth Control (

Gender Preference (M) (F)

Substance Abuse
Alcohol (

Remarks:

Smoking (

Drug Usage (
Employment

)
Remarks:

Exposure to Carcinogens or

Remarks:

Environmental Agents

Systems Review
Skin

Remarks:

Rashes (

Lumps (

Dryness(

Sores (

Bruising (

Itchiness (

Skin Discolorations (

Head

Remarks:

Headaches (

Dizziness (

Tenderness (

Lumps/Masses (

)
History of:
Trauma (

Seizure (

Head

Eyes

Remarks:

Visual Changes (

Diplopia (

)
Inflammation (

Redness (

Blurring of

)
Discoloration (

Remarks:

Vision (

Lenses (

Wear Glasses/contact
)
Remarks:

Ears
Tinnitus (
Pain (

Vertigo (

Discharge (

Hearing Aids (

Change in Hearing sensation (

)
Remarks:

Nose
Nose Bleeds ( )
Discharge ( )
Sinus Disease ( ) Change in sense of
smell ( )

Remarks:

Mouth and Throat

Hoarseness (
Diseases (
Pain (

Dental

Sore Throat (

Sore tongue (
Gums (

Bleeding

Odor (

Dry Mouth (

)
Remarks:

Neck
Lumps (

Stiffness (

Pain (

)
Remarks:

Respiratory
Cough (

Shortness Of Breath (
Hemoptysis (
Dyspnea (
Sputum (

)
)

Color ______

PTB Hx: (
Tx (Y)

Amount ________

)
(N)

year_______

Vaccination for Influenza or

Pneumococcus (

Cardiovascular

)
Remarks:

Chest Pain (

Orthopnea (

Extremity Edema (
Claudication (

Dtspnea on Exertion (

)
Remarks:

Gastrointestinal
Dysphagia (

Vomiting (

Diarrhea (

Constipation (
Jaundice (

Hemorroids (

Bloody Stool ( )
Melena ( )
Hematamesis ( )
Abdominal Pain (

Pain with Defecation (

Excessive Passing of Gas (

)
Remarks:

Urinary
Frequency ____________
Dysuria (
Polyuria

)
(

Hematouria (
Discharge (

)
)

Pain on Urination (
Hesitancy (

Genital
FEMALE
Age of Menarche

MALE
Sexually Transmitted Infection (
__________

______________

LMP

______________

Intervals

________/month

Testicular Pain (

Frequency

________

Testicular Mass (

Duration of Periods __________days

Hernias (

Penile Discharge (

Dysmenorrhoea (

days

Sores (

Itching (

Premenstrual Tension (
)

Bleeding b/w Intercourse (

Vasectomy (

Drive ____________

Itching (

Lumps (

Sores (

Last Pelvic Exam ____________

Last Pap Smear
Menopause (
Bleeding (

____________
) Post Menopausal

Vaginal Discharge (

Sexually Transmitted Infection (

__________
Tx
(Y)
Remarks:

Endocrine
Polyuria (

Polydypsia (

)
Polyphagia (
Changes (

Skin/ Hair

Hormonal therapy (

Cold/ Heat Intollerance (

Musculoskeletal
Joint Pain / Swelling (
Cramps (

Arthritis (

Twitching (
Stiffness (

Back/
)

Able to do ROM (Y)

Lymph Nodes

Remarks:

Muscle Pain (

Cervical (

(N)
Remarks:
Auxillary (

(N)

Supraclavicular (

Inguinal

Nodes ( )
Psychological
Depression (

Remarks:
)

Anxiety (

)
Adverse Attitudes (
swings (

Mood

Mental Problems (
General:
Weight gain (

)
loss (

gain (

Appetite
loss (
Chills (
Fever (

)
)

Fatigue (

Night Sweats (

Weakness (

Memory Loss (

Confusion (

REMARKS:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

II. Inspection(Somatic Motor)

A. How the patient sits, stands, walks and gestures.
Posture (Standing)
Tremors
( ) Left
( )Right
Remarks______________________________________________________________
_______________________________________________________________________
__
Posture (Sitting)
Tremors

( ) Left

( )Right

Remarks______________________________________________________________
_______________________________________________________________________
__
Gen. Activity Level
Tremors
( ) Left
( ) Right
Remarks______________________________________________________________
_______________________________________________________________________
__
STATION AND GAIT TESTING
How

the

patient

walk:_________________________________________________________
On
toes:________________________________________________________________
On heels:______________________________________________________________
On
tandem:_____________________________________________________________
B. Palpation (Somatotype or Body Build)
Upper Extremities Left
Right
( ) body asymmetry
( ) body asymmetry
( ) atrophy
( ) atrophy
( ) hypertrophy
( ) hypertrophy
Lower Extremities Left
Right
( ) body asymmetry
( ) body asymmetry
( ) atrophy
( ) atrophy
( ) hypertrophy
( ) hypertrophy
C.Muscle Tone
Spaticity
Clonus
Flaccid
Rigidity

( ) Left
( ) Left
( ) Left
( ) Left

( ) Right
( ) Right
( ) Right
( ) Right

Remarks_____________________________________________________________________
__

III. Test for Muscular Weakness

A. Range of Motion (ROM)

Test for ROM by letting patient elevate his/her arms sideways, upfront and
above his/her head.
Remarks: ____________________________________________________________________
B. Neck Muscles
1. Flexor
Let Pt flex his chin to chest slightly. Ex places one palm on forehead of the
Pt and the other at the back. Instruct Pt to flex neck while Ex resists force.
Muscle Strength:
5

Remarks:

2. Extensor
Ex places one palm on occiput of Pt. and the other on the chest of Pt.
Instruct Pt to extend neck backwards while Ex resists force.
Muscle Strength:
5

Remarks:
___________________________________________________________________________

C. Shoulder Muscles and shoulder girdle

1. Arm Elevation
Request patient to hold the arms straight out to the sides. Press down on
both arms at a point where you expect your strength to approximate the
patients
Muscle Strength:
Right Side

Left Side
5
Remarks:
___________________________________________________________________________
2. Arm Adduction downward
Request Pt to extend his/her arms to the sides and resist your force to
elevate them.
Muscle Strength:
Right Side
5

Left Side
5

Remarks:
___________________________________________________________________________
3. Arm adduction across the chest (pectoralis muscle)
Request Pt to extend his/her arms in front and cross his wrists. Make
patient resist while you pull them apart.
Muscle Strength:
Right Side
5

Left Side
5

Remarks:
___________________________________________________________________________
4. Scapular adduction
With the hands on the hips, the patient forces the elbows backward as
hard as possible. The Ex tries to push them forward while behind the Pt.
Muscle Strength:
Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________
5. Scapular winging
Request Pt to lean forward against a wall, supporting the body with
outstretched arms.
Winging:
Remarks:
______________________________________________________________________

D. Upper Arm Muscles

1. Elbow Flexor
Pt tightly flexes forearm. Ex braces one hand against Pts shoulder and the
other hand grasping the Pts wrist attempting to straighten the Pts
forearm.
Muscle Strength:

Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________
2. Elbow extensor
Request Pt to extend forearm while biceps are in the flexed position. Ex
resists the force.
Muscle Strength:
Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________
E. Forearm Muscles
1. Wrist Flexor
The Pt makes a fist and holds the wrist flexed against Exs efforts to
extend it.
Muscle Strength:
Right Side
5

Left Side
5

Remarks:
___________________________________________________________________________
2. Wrist Extensor
Request pt. to make a fist then place it on top of a flat surface for support.
Pt extends wrist (dorsiflex) while resisting Exs force to flex it down.
Muscle Strength:
Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________
F. Finger Muscles
1. Abduction- Adduction of the fingers
Request pt to Adduct and Abduct Pts fingers against Exs fingers.
Remarks:
___________________________________________________________________________
2. Finger Extension
Request Pt. to hold out arms palms down and fingers extended. Ex turns
his/her arms over so the fingernails presses against the dorsum of the
Pts.
Muscle Strength:
Right Side

Left Side
5
Remarks:
___________________________________________________________________________
3. Finger Flexion
Request Pt to squeeze Exs two fingers. Ex then tries to pull fingers out of
Pts grip while Pt resists it.
Muscle Strength:
Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________
G. Abdominal Muscle
Request Pt to lie down in a supine position. Ask the patient to do a sit-up.
Observe the umbilicus.
Umbilicus position:
Center

Upward

Downward

Left

Right

Remarks:
______________________________________________________________________________

H. Large Back Muscles

Request Pt to lie in prone position while arching his/her back
Remarks:
______________________________________________________________________________

I.

Hip girdle
1. Hip flexion
Request Pt to lift a knee off of the table surface and to hold the thigh in a
flexed position. Ex tries to push knee back down using his/her palm
Muscle Strength:
Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________
2. Hip Extension
Pt extends thighs backwards while Ex tries to flex it.
Muscle Strength:
Right Side
5

Left Side
5
Remarks:

___________________________________________________________________________
3. Thigh abduction and adduction
With Pt sitting, request Pt to hold the legs abducted while Ex tries to
adduct them. Then Ex asks Pt to hold the legs adducted while Ex tries to
abduct them.
Muscle Strength:
ADDUCTION
Right Side
5

Left Side
5
ABDUCTION
Right Side
5
Left Side
5
Remarks:
___________________________________________________________________________
J.

Thigh Muscles
1. Knee extensor
Have the Pt extend knee towards buttocks while Ex opposes it
Muscle Strength:
Right Side
5

Left Side
5

Remarks:
___________________________________________________________________________
2. Knee Flexor
Pt holds the knee at angle of 90 degrees while Ex tries to straighten it by
grasping the Pts ankle.
Muscle Strength:
Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________
K. Ankle and Toe movements
Have the Ptdorsiflex, invert and evert the feet
DORSIFLEXION
Muscle Strength:
Right Side
5

Left Side
5
Remarks:

___________________________________________________________________________
INVERSION
Muscle Strength:
Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________
EVERSION
Muscle Strength:
Right Side
5

Left Side
5
Remarks:
___________________________________________________________________________

IV.Muscle Stretch Reflex(Deep)

Jaw reflex
With the patients jaw sagging loosely open, the examiner rests a
finger across the tip and strikes it a crisp blow
Biceps reflex

The examiners thumb places slight tension on the patients biseps

tendon, the lacetusfibrosus. The examiner strikes his thumbnail a crisp
blow
Triceps Reflex
A) Dangle the patients forearm over your hand and strike the triceps
tendon
B) Cradle the patients forearm in your hand and strike the triceps tendon
Brachioradialis Reflex
Cradle the patients forearm in one hand, placing the thumb on the
radius. The hammer strikes the examiners thumbnail rather than the
patients radius. Dont whack away on the patients unprotected bone.
the
Finger Flexion (Tromners method)
The examiner supports the patients completely relaxed hand and
briskly flips the patients distal phalanx upward, as though to flip a
handful of water high into the air. The patients fingers and thumb flex
and response to the stretch of the finger flexor muscles.
Finger Flexion (Hoffmans method)
The examiner depresses the distal phalanx and allows it to flip up. The
extensor of the phalanx stretches the flexor muscles, causing the
fingers and thumb to flex. This method is only effective with very brisk
muscle stretch reflexes.
Quadriceps Femoris Reflex
A) With the patient sitting:
The examiner strikes the patellar tendon a crisp blow. By placing a
hand on the patients knee, the examiner feels and sees the
magnitude of the response
B) With the patient supine:
The examiner bends the patients leg to place slight tension in the
patellar tendon. The blow then will deform the tendon and transmit a
stretch to the muscle
Triceps Surae Reflex

A) With the pt. sitting:

With relaxed leg, the examiner dorsiflexes the foot to place slight
tension on the triceps surae muscle. Try reinforcement if no reflex
occurs
B) With the pt. supine:
With the knees bent and relaxed, the examiner dorsiflexes the
patients foot to place a slight tension on the triceps surae muscle. Try
reinforcement if no reflex occurs

Toe flexion Reflex (Rossolimos sign)

Identical with the finger flexion method. Tapping the ball of the foot
elicits toe flexio
Grading of muscle stretch reflex
0
Areflexia
1
Hyporeflexia
2
Normal
3
Hyperreflexia
4
Clonus present

Muscle stretch reflex

Grade
L

Jaw Reflex
Biceps Reflex
Triceps Reflex
Brachioradialis Reflex
Finger Flexion (Tromners method)
Finger Flexion (Hoffmans method)
Quadriceps Femoris Reflex
Triceps Surae Reflex
Toe flexion Reflex (Rossolimos sign)

Inspection while at Rest

Flaccid / Floppy:
Uncomfortable Joint
Position:
Rag Doll Posture:
Inspection while walking
Flaccid / Floppy:
Arms fail to swing
properly:
Hypotonic Stretch reflexes / Pendulous:

Rombergs test:

V.Skin and muscle (superficial) reflexes

Plantar Reflex
1. Position the patient in a supine position with the limbs relaxed and
symmetrically arranged, with the knees straight or slightly flexed and
turned.
2. Inform the patient that the procedure might be uncomfortable by
saying: I am going to press your foot gently. If its unpleasant, tell
me.
3. Hold the patients ankle with one hand to keep the foot in place and
control the pressure of the plantar stroke.
4. Place the stimulus object (serrated, broken end of a tongue blade) at
the patients heel stopping short at the base of the foot.
5. Begin with a very slight pressure or even apply the stroke at the
lateral aspect of the foot, (ChaddocksManeuver) a region less sensitive
than the sole.
6. Stroke it slowly along the lateral margin of the foot.
7. If no response or inconstant responses occur the stimulus is
probably wrong. Try again and consider the following:

A. Length: Increase length by swinging the stroke across the ball

of the foot
B. Velocity
C. Pressure: Increase the pressure but remain short of pain and
within the patients

Limit of Tolerance
RESULT

Eponym

Maneuver

flexion
extension
Babinski
(Plantar toe
reflex)
Chaddocks
Maneuver
Schaeffer
(Achilles-toe
reflex)
Oppenheim
(Shin-toe
reflex)

Move an
object along
the lateral
aspect of the
sole.
Move an
object along
the lateral side
of the foot.
Squeeze hard
on the Achilles
tendon.
Press your
knuckles on
the patients
shin and move
them down.

Gordon (Calftoe reflex)

Bing (Pinpricktoe reflex)

Gonda,
Stransky (Toepull reflex)

Squeeze the
calf muscles
momentarily.
Make multiple
light pinpricks
on the
dorsolateral
surface of the
foot.
Pull the fourth
toe outward
and downward
for a brief time
and release
suddenly.

Normal Variations
A. Flexion synergy- some normal person will shoe little or no
movement after plantar stimulus and this is called mute Sole.
palpate the extensor hallucislongus tendon, if mechanical factors
prevent the movement

B. Triple flexion synergy- the withdrawal movement like: 1. Dorsiflexion

of the ankle 2. Flexion of the knee 3. Flexion of the knee. These are
normal response of a person like stepping on a sharp object.

C. Small toes may fan but it is not a clinically important part of the
plantar reflex
VI. Cerebellar Examination
I. Initial Observation
Remarks:_________________________________________________________

A. SPEECH (/X)

Ask patient to state his/her name/address/birthday etc.

Slurred: ( )

Fluent: ( )

Mute: ( )

Remarks:_________________________________________________________

B. EYE MOVEMENT (/X)

1.) Ask Pt to look straight ahead and place your fingers in the temporal fields.
2.)AskPt to look first at one finger and then the other and then direct the Pt to
look rapidly from one to the other several times

Dysmetria of saccades:

( ) R: ( ) L: ( )

Jerky rather than smooth:

( ) R: ( ) L: ( )

Slowness in initiating movement:

( ) R: ( ) L: ( )

Skew movement:

( ) R: ( ) L: ( )

Remarks:_________________________________________________________

C.STANCE and GAIT(/X)

1.) Ask Pt to stand with feet together
2.)AskPt to walk towards a straight line
3.)Tandem Walking (ask Pt to walk on a straight line,placing heel to one foot
directly in front of the toe of the other)

Swaying when standing: ( )

based Gait: ( )

Broad-based stance: ( )

Broad-

Remarks:__________________________________________________________

D. ARMS (/X)

1. Finger-to-nose test & Decomposition of movement

a.) Ask Pt to extend arms straight out in front
Wavering of arms:
Rhythmic postural tremor:

( ) R: ( ) L: ( )
( ) R: ( ) L: ( )

Remarks:__________________________________________________________

b.) Ask Pt to be in bat wing's position (hold finger apart in front of the nose,
with arms elevated horizontally)

Wavering of arms:
Rhythmic postural tremor:

( ) R: ( ) L: ( )
( ) R: ( ) L: ( )

Remarks:__________________________________________________________

c.) Ask the Pt to hold arms straight out and then instruct to place index finger
on the tip of his/her nose.
Dystaxia increases as finger approaches
nose (intention type of kinetic tremor):

( ) R: ( ) L: ( )

Pt fails to precisely place tip of finger to

tip of nose (dysmetria)

( ) R: ( ) L: ( )

Remarks:__________________________________________________________

d.) Movement 1:
Ask Pt to move arm from side to level of nose
Unsuccessful
Long inefficient trajectory

( ) R: ( ) L: ( )
( ) R: ( ) L: ( )

Remarks:__________________________________________________________

e.) Movement 2:
Ask Pt to bring fingertip to nose
Unsuccessful
Long inefficient trajectory

( ) R: ( ) L: ( )
( ) R: ( ) L: ( )

Remarks:__________________________________________________________

f.) Ask Pt to alternately touch his/her nose, Exs finger, then back to his/her
nose several times
(Dystaxia) increases as finger approaches
nose (intention type of kinetic tremor):

( ) R: ( ) L: ( )

Pt fails to precisely place tip of finger to

tip of nose (dysmetria)

( ) R: ( ) L: ( )

Remarks:__________________________________________________________

2. Thigh-Patting Test (for Dysdiadochokinesia)

a.) Demonstrate by lightly slapping own thigh, alternating first by slapping
the palm and then the back of the hand,as rapidly and rhythmically as
possible.
Overshooting:
Undershooting :

( ) R: ( ) L: ( )
( ) R: ( ) L: ( )

Remarks:__________________________________________________________

b.) Make an audible sound with each pat.

Slower than normal sound rhythm:
c.) Ask Pt to make actions that sound exactly like
d.) Test hands separately and together

( ) R: ( ) L: ( )

Slower than normal sound rhythm:

( ) R: ( ) L: ( )

Remarks:__________________________________________________________

3. Finger tapping test

a.) Place audiocassette on table and ask Pt to grasp it between thumb and
third digit, leaving index finger free to tap.
Difficulty assuming position or even in
picking up and arranging box:

( ) R: ( ) L: ( )

b.) Ask Pt to tap as rapidly as possible for

10 seconds. (Normal subjects tap at rate

( ) R: ( ) L: ( )

of 50 taps per 10 seconds)

Remarks:__________________________________________________________

4. Wrist-tapping test
a.) Ask patient to stand with eyes closed
and arms outstretched

( ) R: ( ) L: ( )

b.) Ex strikes back of pts wrist to displace

arm

( ) R: ( ) L: ( )

Remarks:__________________________________________________________

5. Arm-pulling test
a.) Ask patient flex R arm
Overshooting forward and backward

( ) R: ( ) L: ( )

b.) Exs L hand pulls Pts arm while R

hand positions at Pts R shoulder for
Face protection
Overshooting forward and backward

( ) R: ( ) L: ( )

c.) Ex suddenly release Pts arm

Overshooting forward and backward

( ) R: ( ) L: ( )

d.) Ex does the same procedure for L arm

Overshooting forward and backward

( ) R: ( ) L: ( )

Remarks:__________________________________________________________

E. LEGS (/X)
1. Heel-to-shin Test
a.) While Pt is supine or sitting, ask him/her to place one heel precisely on
opposite knee
Positional tremor while heel is at knee

( ) R: ( ) L: ( )

b.) Ask Pt to hold heel to knee for few seconds

Accuracy of heel placement and movement

( ) R: ( ) L: ( )

while at knee

c.) Ask Pt to run the heel straightly down the shin

Accuracy of heel placement and movement

( ) R: ( ) L: ( )

while at the shin

Remarks:__________________________________________________________

2. Heel-tapping test
a.) While Pt is supine or sitting, ask him/her to place one heel over the other
shin with heel as rapidly as possible on one spot

Misses spot (dysmetria)

( ) R: ( ) L:

()
Tpsdysrhythmically (dysdiadochokinesia)

( ) R: ( ) L: ( )

Remarks:__________________________________________________________

3. Inspection of Hypotonia and Quadriceps Femoris Reflex

a.) Ask patient to sit and rest
Assumes floppy postures and joint positions

( ):__________

(rag-doll or dumped-in-a-heap postures):

b.) Ask Pt to walk

Presents a floppy, sagging, loose-jointed appearance :
:__________

()

Arms fail to swing properly

( ) R: ( ) L: ( )

Knees bend backward slightly (genu recurvatum)

( ) R: ( ) L: ( )

Head and trunk boba rag-doll gait

( ) R: ( ) L: ( )

(like in drunkenness)

Remarks:__________________________________________________________

c.) Ask Pt to sit with legs swinging freely over table edge.
Leg swings to and fro several times like pendulum

( ) R: ( ) L: (

d.) Ex elicits Quadriceps Muscle Stretch Reflex

Leg swings to and fro several times like pendulum

( ) R: ( ) L: (

)
Remarks:______________________________________________________

That in all things God may be Glorified!

ORA ET LABORA
Regalado, Jocos Louise
Reyes, DanicaDanielle
Reyes, Jordan Gabriel Angelo
Reyes, Kenneth
Rivera, Al Enrico
Rivera, Diandra Marie