"do you have access to an initial eval form for stroke patients? let me know."
Physical Therapy Initial Evaluation – Neurological/Geriatric
Date: _________________ Date of Onset: _________________
Diagnosis: ________________________________ Physician: _________________________________________
History/Mechanism of Injury: _______________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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Psychosocial/Functional Deficits: ___________________________________________________________________
_________________________________________________________________________________________________
PMH: ____________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Current Medications: ______________________________________________________________________________
_________________________________________________________________________________________________
Symptomology/Pain: ______________________________________________________________________________
_________________________________________________________________________________________________
Observation/Inspection: ____________________________________________________________________________
_________________________________________________________________________________________________
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Function: |
Ind |
SBA |
CGA |
HHA |
Min |
Mod |
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N/T |
# of Assist & Comments |
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Bed Mobility- Rolling |
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Supine to Sit |
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Sit to Supine |
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Sit to Stand |
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Stand to Sit |
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Car |
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_________________________ |
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Gait: |
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_________________________ |
Supportive Device: ___________________________________ Distance: _________________________________
Quality: _______________________________________________________________________________________
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Stairs: |
Ind |
SBA |
CGA |
HHA |
Min |
Mod |
Max |
N/T |
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Supportive Device : ____________________________ |
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# of Steps: __________________________ Comments: _________________________________________________
Proprioception: ___________________________________________________________________________________
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Sensation: _______________________________________________________________________________________
_________________________________________________________________________________________________
Coordination/Quality of Movement: __________________________________________________________________
_________________________________________________________________________________________________
Balance: _________________________________________________________________________________________
Patient scored ______________ on Berg Balance Assessment which reveals _________________ balance impairments
Palpation: _______________________________________________________________________________________
Other: ___________________________________________________________________________________________
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+=pain |
AROM L |
AROM R |
PROM L |
PROM R |
Strength L |
Strength R |
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Flexibility: _______________________________________________________________________________________
ASSESSMENT:
Patient is presenting with the following functional deficits:
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YES |
NO |
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Comments |
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Pain: |
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Strength: |
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Edema: |
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ROM / Flexibility: |
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Posture/Biomechanics |
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Gait/stair negotiation |
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Transfers/Bed Mobility |
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Ligament/Structural Deficit: |
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HEP: Patient instructed on and demonstrated HEP consisting of ____________________________________________
INITIAL ASSESSMENT: ___________________________________________________________________________
CURRENT PLAN and FUNCTIONAL GOALS
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CURRENT PLAN |
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Pt to be seen up to ____visits for ___________________________________________________________________ |
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SHORT TERM FUNCTIONAL GOALS |
TIME-FRAME ESTIMATE |
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1. ____________________________________________________________________________
2. ____________________________________________________________________________
3. ____________________________________________________________________________
4. ____________________________________________________________________________
5. ____________________________________________________________________________
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LONG TERM FUNCTIONAL GOALS |
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1. ___________________________________________________________________________________________
2. Pt will be independent with HEP with minimal symptoms and return to functional ADLs.
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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