My Neuro Eval Form 133h5r

Physical Therapy Evaluation/Discharge Summary: Neurological

PRECAUTIONS:

Diagnosis: _______________________________________________ Reason for Referral: __________________________________ Pertinent Medical History: __________________________________________________________________________________ ______________________________________________________________ Social/Home/Language: __________________________________________________________________________________ ______________________________________________________________ Prior Level of Function: ____________________________________________________ Equipment Owned: _______________________________________________________ General Observations/Orientation: [ ] Foley [ ] SCD’s [ ] Incision [ ] Intubated [ ] Family at bedside [ ] Telemetry [ ] IV [ ] PCA

[ ] O2 @[ ]Ltrs/Min [ ] Drain: [ ] TEDS [ ] Other:

Patient/Family Goals for PT: ________________________________________________ ________________________________________________________________________ Cognition/Behavior: [ ] Ready to learn, no barriers __________________________________________________________________ Learning Preference: [ ] Verbal [ ] Written [ ] Demo [ ] Other/Comment: Pain: Y / N Location: Intensity: Quality/Characteristics: Aggravating/Easing Factors: History: Comments:

OBJECTIVE: Functional Mobility: KEY: I=Independent; VC/S=Verbal Cues/Supervision; SBA=Stand By Assist; CG= Guard; Min=Minimal Assist (75-100%); Mod=Moderate Assist (5074%); Max=Maximal Assist (25-49%); N/A=Not Applicable

Rollin: Scooting:

Stand Balance: Static: Dynamic: Gait:

Supine <-> Sit: Chair Transfer: Sit Balance: Static: Dynamic:

Toilet Transfer: Stairs:

Sit <-> Stand: Other: ROM: Range of Motion: R UE: [ ]WFL, [ ]except: L UE: [ ]WFL, [ ]except: R LE: [ ]WFL, [ ]except: L UE: [ ]WFL, [ ]except: Trunk: STRENGTH: R UE: [ /5]Grossly, [ ]except: L UE: [ /5]Grossly, [ ]except: R LE: [ /5]Grossly, [ ]except: L LE: [ /5]Grossly, [ ]except: Trunk: Synergy Dependence: Integument:

Neuro Status: Coordination: Purposeful Movements: Tone: Sensation: [ ] intact [ ] except: Proprioception: [ ] intact [ ] except: Clonus: Babinski: Vision: [ ] WFL [ ] Corrective Lenses [ ] Acuity [ ] Tracking Deficits [ ] Field Cut [ ] Nystagmus [ ] Diplopia

[ ] Inattention [ ]R [ ]L [ ] Edematous Eyelid [ ]R [ ]L [ ] Depth Perception [ ] Other:

Cranial Nerves: [ ]intact [ ]except:

Vital Signs BP HR RR I Endurance Subjective Sxs (Dizziness, N/V, other) Other

Rest

Activity

PT Diagnosis:

PLAN/Assesment: Problem List

Goal (1 week)

Intervention