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Stroke Eval

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Ask a PT View Drop Down
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Joined: Jul 07 2008
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    Posted: Jan 19 2009 at 12:51pm
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: ____________________________________________________________________________

_________________________________________________________________________________________________

Function:

Ind

SBA

CGA

HHA

Min

Mod

Max

N/T

# of Assist & Comments

Bed Mobility- Rolling

_________________________

Supine to Sit

_________________________

Sit to Supine

_________________________

Sit to Stand

_________________________

Stand to Sit

_________________________

Car

_________________________

Gait:

_________________________

 

Supportive Device: ___________________________________     Distance: _________________________________

 

Quality: _______________________________________________________________________________________

 

Page 2

      

Stairs:

Ind

SBA

CGA

HHA

Min

Mod

Max

N/T

Supportive Device : ____________________________

 

# of Steps: __________________________     Comments: _________________________________________________

 

Proprioception: ___________________________________________________________________________________

 

_________________________________________________________________________________________________

 

Sensation: _______________________________________________________________________________________

 

_________________________________________________________________________________________________

 

Coordination/Quality of Movement: __________________________________________________________________

 

_________________________________________________________________________________________________

 

Balance: _________________________________________________________________________________________

 

Patient scored ______________ on Berg Balance Assessment which reveals _________________ balance impairments

 

Palpation: _______________________________________________________________________________________

 

Other: ___________________________________________________________________________________________

 

 

+=pain

AROM L

AROM R

PROM L

PROM R

Strength L

Strength R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Flexibility: _______________________________________________________________________________________


ASSESSMENT:

Patient is presenting with the following functional deficits:

 

YES

NO

 

Comments

 

 

Pain:

 

 

 

Strength:

 

 

 

Edema:

 

 

 

ROM / Flexibility:

 

 

 

Posture/Biomechanics

 

 

 

Gait/stair negotiation

.

 

 

Transfers/Bed Mobility

 

 

 

Ligament/Structural Deficit:

 

 

HEP: Patient instructed on and demonstrated HEP consisting of ____________________________________________

 

INITIAL ASSESSMENT: ___________________________________________________________________________

 

CURRENT PLAN and FUNCTIONAL GOALS

CURRENT PLAN

 

Pt to be seen up to ____visits for ___________________________________________________________________ 

 

SHORT TERM FUNCTIONAL GOALS

TIME-FRAME ESTIMATE

 

1.       ____________________________________________________________________________

 

2.       ____________________________________________________________________________

 

3.       ____________________________________________________________________________

 

4.       ____________________________________________________________________________

 

5.       ____________________________________________________________________________

 

 

 

 

LONG TERM FUNCTIONAL GOALS

 

1.       ___________________________________________________________________________________________

 

2.       Pt will be independent with HEP with minimal symptoms and return to functional ADLs.

 

 

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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