UNIVERSITY OF PRETORIA: FACULTY HEALTH SCIENCES DEPARTMENT OF PHYSIOTHERAPY NEUROLOGY ASSESSMENT

Student: Data Base Patient Name: Gender: Diagnosis: Subjective Interview Patients main complaint/expectations: Age: Date of Evaluation: Hospital number: Student number:

Relevant Health History:

Level of self care:

Eating Dressing Bathing and Grooming Toileting Bedmobility/Rolling Lying to sitting Sit to stand Walking Stairs Fine motor skills

Limitation

Previous Medical/Rehabilitation History:

Present Medical Plan/Treatment:

Participation (socio-economic/role in family/community/society):

Lifestyle/Geographical environment:

Special Questions: General Health (THREAD) .. .. Unexplained weight loss: .............................................. Night pain: ............... Cord signs: ...... Cauda equina: ...... Smoking: ............................................... Medication:

Special investigations:

Level of communication:

Emotional status:

Motivation factors:
Intrinsic

Positive

Negative

Extrinsic

General Impression and Observation Posture in sitting:

Local observation on body chart:

Vision Visual fields: Nystagmus: Convergence: Divergence:

Sensation Upper limb: Lower limb:

Proprioception Upper limb Lower limb - Fine: - Gross: - Fine: - Gross: Coordination Finger-nose test: Heel-shin test: Rapidly alternating movements:

Special Tests/ Outcome Measures

Selective Movements, Postural Tone and Passive ROM

Tone was assessed by using the Modified Motor Ashworth Scale in supine. 0 = No increase in tone 1 = Slight increase in tone, manifested by a catch and release or min resistance till end of range 1+ = Slight increase in tone, catch followed by min resistance throughout remainder (less than ROM) 2 = Marked increase in tone through most of ROM, limb easily moved 3 = Considerable increase in tone, passive movement difficult 4 = Limb rigid in flexion or extension Selective movement Wrist Flexion Extension Elbow Flexion Extension Shoulder Flexion Extension Adduction Abduction Ankle Plantarflexion Dorsiflexion Knee Flexion Extension Hip Flexion Extension Abduction Adduction Trunk Elongation Rotation L R L ROM was passively taken through range and documented as follows: N = Normal = Pain free FROM D = Decreased

Tone R L

ROM R

Functional Assessment

Activity Level Functional Problems Component Analysis

Physiological and Structural Underlying Impairment Reason / Missing components Objective measurement / Observation

Activity Level Functional Problems Component Analysis

Physiological and Structural Underlying Impairment Reason / Missing components Objective measurement / Observation

Summary of problems on all three levels of ICF

Impairment level

Activity level

Participation level

Aims/goals on all three levels of ICF (short term and long term)

Impairment level

Activity level

Participation level

Treatment plan

Activity

Components achieved

Progress Notes