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Ask a PT 
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Joined: Jul 07 2008 Status: Offline Points: 954 |
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 Topic: Stroke EvalPosted: Jan 19 2009 at 12:51pm |
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Our user asked: "do you have access to an initial eval form for stroke patients? let me know."
Ask a PT Response: Here is a copy of a neurological eval at a clinic which I use to work at. I hope this helps.
Physical Therapy Initial Evaluation – Neurological/Geriatric Date: _________________ Date of Onset: _________________ Diagnosis: ________________________________ Physician: _________________________________________ History/Mechanism of Injury: _______________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Psychosocial/Functional Deficits: ___________________________________________________________________ _________________________________________________________________________________________________ PMH: ____________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Current Medications: ______________________________________________________________________________ _________________________________________________________________________________________________ Symptomology/Pain: ______________________________________________________________________________ _________________________________________________________________________________________________ Observation/Inspection: ____________________________________________________________________________ _________________________________________________________________________________________________
Supportive Device: ___________________________________ Distance: _________________________________ Quality: _______________________________________________________________________________________ Page 2
# of Steps: __________________________ Comments: _________________________________________________ Proprioception: ___________________________________________________________________________________ _________________________________________________________________________________________________ Sensation: _______________________________________________________________________________________ _________________________________________________________________________________________________ Coordination/Quality of Movement: __________________________________________________________________ _________________________________________________________________________________________________ Balance: _________________________________________________________________________________________ Patient scored ______________ on Berg Balance Assessment which reveals _________________ balance impairments Palpation: _______________________________________________________________________________________ Other: ___________________________________________________________________________________________
Flexibility: _______________________________________________________________________________________ ASSESSMENT: Patient is presenting with the following functional deficits:
HEP: Patient instructed on and demonstrated HEP consisting of ____________________________________________ INITIAL ASSESSMENT: ___________________________________________________________________________ CURRENT PLAN and FUNCTIONAL GOALS
Patient/family understands above treatment plan and goals. Yes No Barriers to achieving treatment goals? Yes No PAIN MANAGEMENT Patient educated with pain management and is able to perform exercises to effectively manage pain. Yes No N/A __________________________________________________ _______________________ Clinician Date |
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