Sample physiotherapy assessment form.

Name:
D.O.B: Hospital number:
Age:
Address:
Tel No:
Physician name & address:
Date of hospital admission:
Date of assessment:
Diagnosis:
Date of Onset:
Therapist’s name: Signature:

 HISTORY OF THE PRESENT COMPLAINT (HPC)

 RELEVANT PAST MEDICAL HISTORY (PMH)
 SOCIAL HISTORY (SH) (e.g. work, hobbies, family and home conditions, social services and stairs
– bedroom and bathroom, smoker).
 MOBILITY STATUS PREVIOUS MOBILITY
 PATIENTS EXPRESSED GOALS/
 EXPECTATIONS GENERAL OBSERVATIONS
 MENTAL STATE COMMUNICATION
 OROFACIAL FUNCTION CHEST STATUS
 VISION HEARING SWALLOWING/FEEDING
 SENSATION/PERCEPTION

TONE (grading/associated reactions (ARs’) response to handling-specify position of assessment)

SELECTIVE MOVEMENT/ROM/STRENGTH (can they perform the movement independently, or do they

need assistance? If assistance is needed, how much and to what part of body? Describe resting posture
and tone) head/trunk/pelvis upper limbs lower limbs

BALANCE Static (the ability to stay upright over the base of support) Dynamic (the ability of the body to
stay upright during movement of the limbs outside the base of support and to respond to external
environmental perturbations).

GAIT (Note level of assistance required; any gait deviations and use of walking aids) Stance phase
(consider weight transfer onto affected leg; extension of affected hip on weight bearing; heel strike at
initial contact; knee control in mid-stance) Swing phase (consider standing on unaffected leg, swing
through of affected leg with hip flexion, knee extension and dorsiflexion)

FUNCTIONAL MOBILITY (determine general activity level e.g. bed bound, wheelchair dependent,
ambulant; can they perform the movement independently, or do they need assistance? If assistance is
needed, how much and to what part of body?)
In/out of bed:

Lying to sitting:

Sitting to standing:

Stairs/curbs:

Transfers:

 Problem List Treatment Plan

 Patient agreed short-term goals

 Patient agreed long-term goals

 Sample assessment for a patient post CVA

History of present complaint:

68-year-old male; diagnosis of R middle cerebral artery infarct with
left hemiplegia.
Onset: 5 days ago.
Past medical history: Diabetes mellitus, high blood pressure.
Social history: Retired teacher, lives with wife, three grown children
who live nearby. Plays golf weekly.
Previous mobility: Active, independent with no limitations.
Expressed goals: Return home, regain mobility and participate in
recreational activities.
General observations:
● Sitting in bedside chair leaning to R side, tries to correct trunk
position during interview, no spontaneous movements L arm or leg.
● Appears alert and oriented, expressive speech intact, dysarthria
noted, L lower facial paralysis.
● No reports of pain or swallowing difficulties.

Activity level: Wheelchair bound Bed mobility

● Able to roll onto L side; uses R arm and head/upper trunk to initiate
roll. Complaints of L shoulder pain when lying on L side for more than
2 minutes.
● Cannot scoot up or down in bed; can bridge with assistance to
maintain flexed leg position.
● Able to roll onto R side with verbal cues (hold L arm, reach across
body as roll, lift head) and minimal assistance to L leg (when L leg
placed in flexed position on bed, patient can activate leg muscles to
assist movement to side lying.
● Reports L arm feels heavy when he lifts it.
Transfers:
To/from plinth3.
Requires minimal support to R upper trunk and verbal cues from
therapist to initially move trunk forward, requires moderate
assistance when lifting buttocks from chair, rotates body during
transfer with only verbal cues. ● L foot slides forward during
transfers.
Sitting: on plinth
● Sits on plinth with R arm support and can initiate forward fl
exion/extension movements; cannot sit without arm support.
● Trunk leans to R, appears to have more weight on R buttock. Has
diffi culty keeping L foot fl at on fl oor.
● Inferior shoulder subluxation present. Holds L arm in lap.

Sit to stand:

● Needs verbal reminders to scoot forward, and to lean trunk forward. ● Physical assistance needed to
position foot. ● Unable to keep weight over L foot during stand. ● Requires moderate assistance when
lifting buttock from chair. Takes 6–8 sec to rise to stand with assistance. ● Cannot control L knee in
standing; knee buckles. ● Arm postures in 20 degrees elbow flexion during attempt to stand, no
posturing during sitting.

Gait/Stairs: Unable to assess

Selective movement Trunk

Sitting

● When therapist supports pelvis/hips, patient can initiate forward fl exion movements with upper
trunk through 1/2 range; trunk lean to R noted during movement. Ribcage/ spine rotate slightly to L.

● Falls to L when reaching R arm beyond arm’s length. Can lift up R leg in fl exion pattern through 1⁄3
range, further attempts result in loss of sitting balance to L. ● Cannot extend entire spine; tends to rest
in forward fl exion; holds L hand in lap.

● Side bending to R is accompanied by trunk rotation L. Side bending to L possible when therapist
provides stability to L hip/pelvis. Standing: unable to assess.

L Upper limb Sitting

● Forward reach characterized by shoulder elevation, shoulder abduction (20 degrees), elbow fl exion
(30 degrees). No movement of wrist/fi ngers noted. Arm movement is slow and jerky. Arm feels heavy,
but shoulder follows movement; cannot hold positions when handling withdrawn.

● With minimal assistance, patient able to fl ex shoulder to 60 and activate elbow extensors for a brief
period.

● When arms supported on table, patient able to supinate forearm through 1/2 range, active pronation
not possible.

● When forearm stabilized, wrist extension present through 1/2 range.

● No finger fl exion/extension possible. Soft oedema noted on volar and dorsal aspect of hand.

● 1 cm inferior shoulder subluxation at rest. Standing: unable to assess

L Lower extremity Sitting

● Lifts leg in fl exor pattern through 1/2 range. Ankle dorsifl exion with supination noted during lift of
leg. Able to extend knee 45 degrees with ankle plantarfl exion. Unable to isolate active knee or ankle fl
exor movements.

● Ankle joint ROM: dorsifl exion -5 degrees. Plantar fl exion WNL. Supine

● Active hip and knee synergistic fl exor and extensor movements through full range.

● Unable to place or maintain foot on bed in bridging position. With both legs fl exed and L foot
stabilized on bed by therapist, able to rotate both hips L/R, abduct/ adduct L hip, and ‘bridge’.
Sensation

● Light touch: intact upper and lower limb.

● Proprioception: intact shoulder/elbow, hip/knee; impaired wrist/hand, ankle/foot.

● Stereognosis: not assessed.

Activity restrictions

1. Unable to balance and perform washing and dressing activities in sitting.

2. Unable to transfer from chair/bed/plinth.

3. Unable to move from sitting to standing independently.

Relevant impairments

1. Weakness in leg, especially hip.

2. Weakness in trunk (loss of trunk-limb linked patterns).

3. Decreased ankle range and altered proprioception in L ankle/foot.

4. Inability to maintain sufficient weight between legs during extension phase of transfer/stand.

5. Loss of upper body stability

Short-term goals (one week)

1. Independence in bed mobility; rolling to either side, side lying to sitting.

2. Independence in daily washing and upper body dressing in sitting.

3. Transfer from bed/chair/bed with contact guarding. 4. Sit to stand with minimal assistance/ verbal
cues.

Long Term Goals

1. Independence in washing and dressing in standing.

2. Independent sit to stand.

3. Assisted ambulation: walking aid and standby support

Physiotherapy Management

Maintain range of movement to prevent/minimize soft tissue

adaptation
● Active/active assisted/passive movements; joints, muscles most at risk e.g. glenohumeral, ankle,
knee, muscles crossing two joints

● Avoid vigorous or forced movements, vary speed, direction

● Positioning to help maintain ROM

● Mobilization of rib cage, pelvis and jaw (Carter & Edwards 2002)

Prevent/address soft-tissue length changes

● Weight bearing via active means wherever possible; active
standing, sit to stand, strengthening (Carr & Shepherd 2003)
● Splinting/casting (Edwards & Charlton 2002), stretching (Harvey et
al 2002)
● Strengthening (Ada & Canning 2005)

Positioning
● Maintain optimal alignment of body parts (Sharman 2002)

● Vary postures during day and night, using rolls, pillows, wedges, supine, side lying, sitting out
(Thornton & Kilbride 2004)

● Positioning for optimal oxygen saturation (Tyson & Nightingale 2004)

● Positioning/seating to enhance perceptual awareness, communication, swallow and social interaction

(Pope 2002)

Weight bearing/movement re-education

● When patient stable commence programmes of sitting and standing for antigravity activity,
maintenance of length (Carr & Shepherd 1998)

● Initially sit out for 15–20 minutes, adapted ward chair/specialist seating e.g. tilt in space to achieve
optimum postures to maintain length, protect vulnerable joints e.g. glenohumeral, respiration,
communication, social interaction (Pope 2002)

● A standing programme starting with the tilt table (if no/only minimal movement present – Chang
2004) or other standing devices should be introduced to the patient’s routine. Progressive mobilization
against gravity: short periods may only be tolerated initially e.g. 5 minutes (Carter & Edwards 2002)

● Ventilation does not preclude standing or sitting; monitor saturation levels and vital signs (Carter &
Edwards 2002)

● Monitor BP, HR particularly if autonomic disturbance

Re-education of sensation
Through provision of meaningful sensory inputs, normally task orientated, training attention to and
interpretation of sensation

Ataxia:
Training programme concentrating on specific impairments affecting task performance (Carr &
Shepherd 1998)

Gait Re-education
i.e. use of parallel bars, walking aids.