INITIAL EVALUATION

A. GENERAL INFORMATION:
Name:
Address:
Religion:
Date of IE:
Referring Doctor:
Diagnosis:
PT Impression:
B. SUBJECTIVE DATA
Chief Complaints:
History of Present Illness
Maternal History:
Illnesses/Accidents:
Pre-natal:
Peri-natal:
Post-natal:
Intake of unprescribed drugs/ abortificacients:
Attitude towards pregnancy:
Obstetric Score: G____ P____
F____ P____ A____ L____
Smokes: ____Stick/s per day (state if before or during pregnancy)
Drinks alcohol beverages: ____bottle/s per day (state if before or
during pregnancy)
Birth History:
AOG
Nature of Delivery
EDD
Presentation
Place of Delivery
( ) Hilot
( ) Midwife
( ) Obstetrician
APGAR score:
Nutritional History:
Breastfeeding duration
Commercial Milk duration
Solid Food intake started
Quality of food
Feeding Problems
Immunization History:
Introduced & Year:
C. OBJECTIVE DATA:
Physical Examination:
Vital Signs: HR
RR
Temp
BP
Ocular inspection:
Mode of arrival
Level of consciousness
Body built
Deformities as to eyes and etc:
Scars (measurement)
Stitches (number of stitches)
Wound (measurement)

Cortical thumb
Drooling
Swelling/ edema
Opisthotonus
Head Circumference
Measurement
Impression
Palpation:
Fontanelle closure
Temp. as to touch
Crepitation
Pitting/Non-pitting edema
ROM
AROM
(R)

(L)

PROM
(R)

(L)

NORMA
L
VALUES
(AMA)

DIFFERENCE
AROM
(R)
(L)

PROM
(R)
(L)

END
FEEL

END
FEEL

(R)

(L)

SHOULDER
Flexion
Extension
Abduction
ER
ELBOW
Flexion
WRIST
Flexion
Extension
HIP
Flexion
Extension
Abduction
IR
ER
KNEE
Flexion
ANKLE
Dorsiflexion
PF

0 180
0 50
0 180
0 90
0 140
0 60
0 60
0 100
0 30
0 40
0 40
0 50
0 150
0 20
0 40

FUNCTIONAL MUSCLE TEST:

Right
Reach
Grasp
Release
Head control
Trunk control
Rolling
Creeping
Quadruped
Crawling
Balance
Sitting
Standing
Half kneeling
Kneeling

Left

Tolerance

Legend:
1 = no ability
2 = beginning ability
3 = ability w/ abnormal
pattern
4 = near normal

Balance
1 = can assume
2 = assume, cant maintain
3 = assume, maintain, cant
weight shift
4 = all 3 challenges

LLD:
True Leg length Discrepancy:
Femoral (R)___________ (L)___________
Tibial (R)___________ (L)___________
Apparent Leg Length Discrepancy
(R)___________ (L)___________
No Leg length Discrepancy
ADL Analysis:
Ambulation =
Dressing =
Eating =
Personal hygiene =
Toileting =

Tolerance
Poor (-) = tolerates 15min
Poor = 15 30min
Fair (-) = 30 45min
Fair = 45 1hr
Good = >1hr
Grading

Independent
Independent with aids
Requires assistance : Maximum, Moderate,
Minimum, Stand-by assist
Dependent/ Total assistance

Postural Analysis: State position as in sitting or standing

AP VIEW
Head
Shoulder
Hips
Knee
Ankle
LATERAL VIEW
Neck
Upper back
Lower back
Knee

Gait Analysis:
R

Heel Strike
Acceleration
Foot Flat
Midswing
Heel of
Deceleration
Toe of
*Note and indicate any deviation
Prognostication for Ambulation:
1.) Blecks Ambulation Status: Less than 2 years old
Reflexes
Normal
Result
Moro
ATNR
STNR
Placing
+
Parachute
+
Extensor Thrust
Neck Righting
2.) Molnar Index: 2years old and above
( ) Sits independently at 2 years old, child will ambulate at 4 yrs old
( ) Sits at 4 years old, child probably ambulate at 6 years old. With
Assistive device
( ) cant sit at 6 years old, poor prognosis for ambulation
Neurological Examinations:
Reflexes:
DTR:
Legend
0 = areflexia
1 = hyporeflexia ( + )
2 = normoflexia ( ++ )
3 = hyperreflexia ( +++)
4 = clonus ( ++++ )

SENSORY ASSESSMENT:
Stimulus
Response
Significance
Audito
Calling her name
ry
Visual
Light
Prick
Soft brushing
Tactile Two point of
neurohammer and tip of
ballpen
Tone Assessment:
Grading:
0 = normal
1 = presence of catch in movt
2 = wider resistance is felt but with continuation of
movement
3 = greater resistance with difficulty moving
4 = fixed position of extremity
Developmental Milestones:
Newborn
( ) Hands fisted
( ) Flexor predominates
( ) rounded spine in sitting
( ) Grasp reflex
4 months
( ) good head control
( ) midline hand play
( ) laughs
( ) lifts head in prone
7 months
( ) rolls over
( ) maintain sitting
( ) transfer objects
( ) bangs object
10 months
( ) stand alone
( ) creeps on all 4s
( ) cruises
( ) waves bye bye
( ) slight bow leg
( ) lumbar lordosis
14 months
( ) walks, arms at high guard
( ) wide base walking
( ) slight valgus of knees and feet
18 months
( ) walks, arms at low guard
( ) emerging hand dominance
( ) walks backward
( ) heels strike in walking
2 years
( ) begins running
( ) walks up and
down stairs
( ) jumps with both feet
3 years
( ) runs well
( ) catches object with extended arms hugging against body
4 years
( ) walks down stairs with alternating of feet
5 years
( ) hand dominance is expected
( ) catches with hands
( ) skips & tip toes
6 years
( ) efective catch and throwing of ball
7 years
( ) responsible for grooming
( ) comb hair
( ) continuing refinement skill