Physical therapy and Rehabilitation Unit

pediatric Examination and Evaluation sheet

PATENT NAME: .

AGE: ..

Gender:

chief complaint :.............

.

History of present illness:

-date of onset:

-current medications : ..

-Other complaints:

-aggravating and alleviating factors :

- effects of treatment and progress of the symptoms over time :

.
.
-past medical history: surgeries .medication ,other
.
.

Family and social history:

-number of child same condition in family :
-son order :
-Genetic diseases:
-Frequency of same case in the family:
-Smoking in house: yes/no
-Job situations:

Perinatal history:
-mother age:.
-maternal fever or rash: ..
-maternal diabetes:
-drug that taken during pregnancy:
-exposure to radiation:
-duration of pregnancy (normal 37weeks):..
-neonatal jaundice:
-mode of delivery: normal delivery / Cesarean delivery

Done by :
1- Hasan al-khwaldeh

2- Reham alshourafa

Physical examination:

according to gross motor function measure scale or (gmfm scale)

lying and rolling :

- from supine position :
lift head to 45 : yes \ no \ between
head in midline : yes \ no \ between
flexes right hip and knee through full range : yes \ no \ between
flexes left hip and knee through full range : yes \ no \ between
reaches out with right arm, hand crosses midline toward toy : yes \ no \ between
reaches out with left arm, hand crosses midline toward toy : yes \ no \ between
rolls to prone over right side : yes \ no \ between
rolls to prone over left side : yes \ no \ between
-

from prone position :

lifts head upright : yes \ no \ between
on forearms: lifts head upright, elbows ext., chest raised : yes \ no \ between
on forearms: weight on r forearm, fully extends opposite arm forward : yes \ no \ between
on forearms: weight on l forearm, fully extends opposite arm forward : yes \ no \ between
rolls to supine over right side : yes \ no \ between
rolls to sup over left side : yes \ no \ between
pivots to right 90 using extremities : yes \ no \ between
pivots to left 90 using extremities : yes \ no \ between

Sitting :
- from supine position :
hands grasped by examiner : patient pulls himself to sitting with head control : yes \ no \ between
rolls to right side, attains sitting : yes \ no \ between
rolls to left side, attains sitting : yes \ no \ between
-

from sit on mat position :

supported at chest by therapist: lifts head upright, maintains 3 seconds : yes \ no \ between
supported at chest by therapist: lifts head midline, maintains 10 seconds : yes \ no \ between
arm(s) propping: maintains, 5 seconds : yes \ no \ between
maintains, arms free, 3 seconds : yes \ no \ between
with small toy in front: leans forward, touches toy, re-erects without arm propping : yes \ no \
between
touches toy placed 45 behind childs right side, returns to start : yes \ no \ between
touches toy placed 45 behind childs left side, returns to : yes \ no \ between
right side sit: maintains, arms free, 5 seconds : yes \ no \ between
left side sit: maintains, arms free, 5 seconds : yes \ no \ between
lowers to prone with control : yes \ no \ between
with feet in front: attains 4 point over right side : yes \ no \ between
with feet in front: attains 4 point over left side : yes \ no \ between
pivots 90, without arms assisting : yes \ no \ between
sit on bench: maintains, arms and feet free, 10 seconds : yes \ no \ between

Done by :
1- Hasan al-khwaldeh

2- Reham alshourafa

on the floor:
attains sit on small bench: yes \ no \ between
attains sit on large bench : yes \ no \ between
- from standing position :
attains sit on small bench : yes \ no \ between
Crawling and kneeling :
- from prone position :
creeps forward 1.8m : yes \ no \ between
attains 4 point, weight on hands and knees : yes \ no \ between
attains sit arms free : yes \ no \ between

from 4 point position :

maintains, weight on hands and knees, 10 seconds : yes \ no \ between
reaches forward with right arm, hand above shoulder level : yes \ no \ between
reaches forward with left arm, hand above shoulder level : yes \ no \ between
crawls or hitches forward 1.8m : yes \ no \ between
crawls reciprocally forward 1.8m
crawls up 4 steps on hands and knees/feet : yes \ no \ between
crawls backwards down 4 steps on hands and knees/feet : yes \ no \ between

from sit on mat position :

attains high kneeling using arms, maintains, arms free, 10 seconds : yes \ no \ between

from high kneeling position :

attains half kneeling on right knee using arms, maintains, arms free, 10 seconds : yes \ no \ between
attains half kneeling on left knee using arms, maintains, arms free, 10 seconds : yes \ no \ between
knee walks forward 10 steps, arms free : yes \ no \ between

Standing :
- On the floor position :
on the floor: pulls to stand at large bench : yes \ no \ between
-

standing position :
maintains, arms free, 3 seconds : yes \ no \ between
holding on to large bench with one hand, lifts r foot, 3 seconds : yes \ no \ between
holding on to large bench with one hand, lifts l foot, 3 seconds : yes \ no \ between
maintains, arms free, 20 seconds : yes \ no \ between
lifts left foot, arms free, 10 seconds : yes \ no \ between
lifts rright foot, arms free, 10 seconds : yes \ no \ between

sit on small bench position :

attains std without using arms : yes \ no \ between

Done by :
1- Hasan al-khwaldeh

2- Reham alshourafa

high kneeling position :

attains std through half kn on right knee, without using arms : yes \ no \ between
attains std through half kn on left knee, without using arms : yes \ no \ between

back to standing :
lowers to sit on floor with control, arms free : yes \ no \ between
attains squat, arms free : yes \ no \ between
picks up object from floor, arms free, returns to stand : yes \ no \ between

walking , running , jumping :

- from standing position :
2 hands on large bench: cruises 5 steps to right : yes \ no \ between
2 hands on large bench: cruises 5 steps to left : yes \ no \ between
2 hands held: walks forward 10 steps : yes \ no \ between
1 hand held: walks forward 10 steps : yes \ no \ between
walks forward 10 steps : yes \ no \ between
walks forward 10 steps, stops, turns 180, returns : yes \ no \ between
walks backward 10 steps : yes \ no \ between
walks forward 10 steps, carrying a large object with 2 hands : yes \ no \ between
walks forward 10 consecutive steps between parallel lines 20cm apart : yes \ no \ between
walks forward 10 consecutive steps on a straight line 2cm wide : yes \ no \ between
steps over stick at knee level, r foot leading : yes \ no \ between
steps over stick at knee level, l foot leading : yes \ no \ between
runs 4.5m stops & returns : yes \ no \ between
kicks ball with r foot : yes \ no \ between
kicks ball with l foot : yes \ no \ between
jumps 30cm high, both feet simultaneously : yes \ no \ between
jumps forward 30 cm , both feet simultaneously : yes \ no \ between
hops on r foot 10 times within a 60cm circle : yes \ no \ between
hops on l foot 10 times within a 60cm circle : yes \ no \ between
holding 1 rail: walks up 4 steps, holding 1 rail, alternating feet : yes \ no \ between
holding 1 rail: walks down 4 steps, holding 1 rail, alternating feet : yes \ no \ between
walks up 4 steps, alternating feet : yes \ no \ between
walks down 4 steps, alternating feet : yes \ no \ between
std on 15cm (6") step: jumps off, both feet simultaneously : yes \ no \ between

Primitive reflexes:
Moro reflex : + , Babinski reflex : + , Asymmetric tonic neck reflex : + , Stepping reflex : + , Symmetric tonic reflexes : + , -

Deep tendon reflexes:

Achilles : + , -

Done by :
1- Hasan al-khwaldeh

2- Reham alshourafa

Biceps : + , Brachioradialis : + , Triceps : + , Patellar : + , -

MMT :
Muscle group

muscle power description

Non functional Weak functional functional

Shoulder flexors
Shoulder extensors
Shoulder abductors
Shoulder internal rotators
Shoulder external rotators
Shoulder horizontal abductors
Shoulder horizontal adductors
Elbow flexor
Elbow extensor
Elbow supinators
Elbow pronators
Hip flexors
Hip extensors
Hip abductors
Hip adductors
Hip internal rotators
Hip external rotators
Knee flexors
Knee extensors
Ankle dorsiflexors
Ankle planterflexors

Sensory examination :
.
.
.
.

Balance :
.
.
.
.

Muscle tone:
Hypertonic ( spastic )

normal

hypotonic ( flaccid )

Other investigation :

Done by :
1- Hasan al-khwaldeh

2- Reham alshourafa

.
.
.
.

Plane of care:
- Problem list :
.
.
.
.
.
.
-Short term goals:
1-
2-
3-
4-
-Long term goals:
1-
2-
3-
4-

Treatment plane and Procedural intervention

Done by :
1- Hasan al-khwaldeh

2- Reham alshourafa

Therapist name: .
Date of examination: / /2013

Done by :
1- Hasan al-khwaldeh

2- Reham alshourafa