CyberPT Physical Therapy Forum : Stroke Eval

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