INITIAL EVALUATION

General Information
Pts Name:
Age:
Sex:
Address:
Civil Status:
Handedness:
Occupation:
Referring Unit: OPD or _____ Ward
Referring MD:
Rehab MD:
Date of Consultation: (OP)/ Admission (IP)
Date of Referral:
Date of IE:
Diagnosis:

Subjective:
Chief Complaint
Can state verbatim or translate
Note initial RPE if cardiac or pulmo pt.
HPI (History of Present Illness)
Present condition started ____
days/wks/mons/yrs
prior to PTIE
*Pertinent questions to ask to the patient in
order to formulate your IE.
1. Why the pt. has come for help?
- this is the prob. or c/c
2. When did the prob start or how long has
the problem existed?
3. Is there any inciting trauma? What
happened?
4. Was the onset slow or sudden?
5. Where are the sx that bothers the pt.?
- localized?
- radiate?
- unable to localize sx?
6. For pain:
a. what are the exact activities or
movements that cause pain?
- what aggravates/ trigger the sx?
-what relieves pain?
-quantify pain- pain scale or min.,
mod., severe
-type and quantity of pain
b. is pain constant? Periodic? Episodic?
Occasional?
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-associated with rest, activity, certain

postures, visceral functions, time of
day
7. For joint problems, ligaments and menisci
-does it exhibit locking, unlocking,
twinges,
Instability?
*For cases of cervical myelopathy:
- has the pt. experienced any bilateral
cord symptoms, fainting, and drop
attacks?
8. Dizziness/ vertigo (synonymous but
vertigo is more
Severe than dizziness.)
9. What did you do about the problem?
-self-medication, hilot, ignored, etc.
10. What made pt. seek medical advice?
-what were done by pt.?
X-rays, CT scan, MRI, Doppler US,
ECG, EMGNCV etc.
-meds given
-NOTE: these data can be included
under lab
Results and meds taken
PMHx (Past Medical History)
Any condition in the past that may
affect the present condition or
treatment.
Has the condition occurred before?
date?
Write unremarkable or
insignificant if none
HTN - controlled/ uncontrolled
-since when?
DM
-type?
-since when?
Hx of trauma relevant to case
Hx of major illness (write the date/
hospital)
Hx of surgery relevant to case
Hx of allergies
FMHx (Family Medical History)
Anything in the family hx that maybe
related to the condition at present.
Write unremarkable or
insignificant if none
HTN, DM, cardiac disease, cancer,
AIDS, PTB, asthma, scoliosis, CP, etc.
(any case that has familial
predisposition relevant to pts case)

Ancillary Procedures/ Laboratory Exams

X-rays, CT- scans, MRI, Doppler US
Cytologic and bacteriologic tests
EMG-NCV, ECG, telemetry, oximetry,
PFTs, etc.

Medication taken (if significant)

Environmental Assessment (only if

applicable)
Type of house (bungalow type, etc.)
Note the presence of stairs, ramps,
etc.
Height of steps, # of steps, amt of
inclination for ramps, presence of
railing
Distance between rooms
How far is work from pt.s home
Width of door/ entrance
Toilet seat height and presence of
hand rail
Type of floor (e.g. non-skid vinyl)
Home Situation/ Family Support/
Economic Background
Who lives with the pt. that takes care
of the pt.?
Is the pt. the head of the family?
Is the pt. financially capable of
acquiring physical therapy services or
continuing physical rehabilitation?
Prior

Level of Function/ Lifestyle

Occupation
Lifestyle- sedentary/ active/ etc.
Smoker?
# of sticks per day x age
# of sticks per pack
Alcohol beverage drinker (note only if
necessary)

Patients Goal/s

Objective:
Vital Signs: BP=___mmHg
PR=___bpm
RR=___cpm
T = ___degrees Celsius
OI:
Initial Evaluation-LORMA

Manner of presentation
Without assistance
Supervision: close guarding, contact
guarding
with assist- level: min, mod, max (+___
assist)
with assistive device-(type, amount of
WB, type of appliance, laterality)
w/c , stretcher, mother-borne, etc.
Bed-ridden, bed bound, bed fast
Level of consciousness- alert,
confused, lethargic, obtunded,
stuporous, comatose
Attitude of patient- apprehensive,
restless, resentful, depressed
Body type- mesomorph, ectomorph,
endomorph
Observe for all (+) findings then
record in cephalo-caudal manner
(dont forget the body part where it is
observed and the laterality)
Atrophy, swelling, hypertrophy
Gait deviations
Postural asymmetry
Bony deformities
Wound/ scar (new scar- red, old scarwhite, hypertrophic or keloid)
(if not a wound case/ problem)
- Size, color, shape, depth, odor
Callosities, blisters, inflamed bursa,
sinuses
Crepitus, Snapping, Clicking sounds
Other abnormal findings
All attachments that you can find
(indicate the laterality)
IV line, ECG monitor and lead wires,
NGT, T-tube, thoracostomy tube, O2
cannula, O2 mask, prosthesis,
orthosis, cast, bandage, wound
dressings
Changes in skin color (redinflammation, bluish/cyanosis-poor
perfusion) and condition (skin
elasticity, shiny skin, hair loss,
ecchymosis (if significant)
Note for all important (-)findings
(pertinent to case)

Palpation:
*(where? Laterality?)
*Choose only those that are significant
Feel variations in skin To/ tissue To
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-hypo-, hyper-, normothermic

Discriminate tissue tension
- Tone (for neuro cases, include this
under tone assessment)
- ms spasm, ms guarding
- distinguish between tissue texture
e.g. MPS, fibrous bands or nodules
identify bony deformities
edema
determine tissue tenderness- add
grade of tenderness
feel tremors and fasciculation
feel dryness and excessive skin
moisture
crepitus
- soft/ fine- cartilage
- course - bone
- creaking/ leathery tendon
amount of subluxation- measure in
fingers-breadth
Note: document all (+) 1st before sig.
(-) findings
If palpation will trigger Sx in pt.,
perform this test last during the
evaluation

ROM:
Motions of (B) UE/LE, neck and trunk
were assessed actively, pain-free and are
WNL except for the ff: (if there are
maximum of 5 joints with LOM)
Joint & AROM PRO
N
Diff
Endfe
laterali
M
el
ty
OR
Active ROM of (B) UE/LE, head and
trunk revealed findings that are WNL and
pain free. The ff joints were assessed
passively with the ff findings:
Joint &
laterali
ty

PROM

Diff

Endfeel

Sig: (take note of lecture on selective tissue

tension testing)
LOM 2o to pain on {(B) active and
passive maybe limited}
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LOM 2o to contracture {(B) active and

passive maybe limited}
LOM 2o to tightness (usually active is
limited but passive is normal or nearly
(N)
LOM 2o to weakness (active is limited,
passive is (N)

MMT
Resisted isometric testing revealed
grade
of ___ (5/5 or 4/5) for the ms of (B) UE/LE
head and trunk.( If with weakness, continue
with..)
except for the ff ms wherein standard MMT
was used.
Muscle
Grade
OR
All major muscles of (B) UE/LE were
grossly graded ____ (5/5 or 4/5 etc)
Note:
- Break test was used
- Resisted Isometric Testing
Note: If you see these two for pain or
contracture, no need to document
using RANGE Grade
In cases of contracture or pain, using
MMT will require documentation of
range grade
Note: available range/ grd of ms.
For SCI, may use ASIA chart to
document ms strength
For UMNL, use FMT instead of MMT as
heading (or in cases of extreme/
severe pain)
Use NWB functional act. for (B) UE
Use WB functional act. for (B) LE (or
upright motor control test for LE)
Use functional activities for trunk;
reaching, lateral flexion, supine, prone
For children, use Pedia MMT or FMT
Sig: ms weakness 2o to
- Inactivity
- Immobilization
- Disuse
- Denervation
- Tendon/ ms rupture

SPECIAL TESTS
Use only those that will confirm the
diagnosis and are sig. to the case. It is
not our duty to rule out diagnosis; can
only be used to confirm a difficult
diagnosis
Significance: Give significance for
each test that you have used
Every test has a corresponding
significance or use.
NEURO EVALUATION
Sensory Testing
If not neuro cases, separate testing or only if
necessary
Superficial sensation:
- Note for STDs used (pin prick
for pain, brush for light touch
and thumb for pressure)
- Pt. has intact sensation as to
pain, light touch and pressure
- Pt. has _____% sensory deficit as
to
_______ (sensation) on where
- For affectation of peripheral or
cutaneous innervations, test
isolated area supplied by the
nerve
- Documentation for dermatomal/
cutaneous distribution, testing,
may draw past tested & or
isolated distribution of nerve.
Significance:
- Hyperesthesia/ hypoesthesia 2
to:
Affectation? _______ nerve
_______ dermatome
Broddman area
3,2,1
Thalamus
ALTS
- Hyperesthesia 2 to pain
- Note whether distal or proximal
part of body has been assessed.

Deep Sensation
- Assess for movement and
position sense
- Intact proprioception on (B)
UE/LE
- Note that this is tested using
distal body parts.

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Cortical Sensation
- Perform stereognosis (if cannot
manipulate with hands, use
graphesthesia)
- Tactile localization, 2-pt.
discrimination,
Bilateral simultaneous
stimulation
- You can use the ff terms:
Intact, Decreased, Exaggerate,
Inaccurate, Absent,
Inconsistent, Ambiguous

MSRs
For neuro case, for ortho cases with
affectation of nerve roots or peripheral
innervations
Legend:
0
areflexia
1+
hyporeflexia
2+
normoreflexia
3+
hypereflexia
4+
clonus

Give first findings- e.g pt. is

normoreflexive
Sig: intact reflex arc ( or what is
appropriate)

Tone Assessment
Use terms: hypo-, hyper-, normo-tonic
and the laterality and limb tested
e.g. (+) gr. 1 spasticity on (B) LE
(Ashworth Scale)
Sig. spasticity 2 to _____
Rigidity 2 to ______
Dystonia 2 to ______
Paratonia 2 to ______
Flaccidity 2 to ______
Clinical Rating Scale used to assess
tone:
0- No response (flaccidity)
1+ Decreased response (hypotonia)

2+ Normal response
3+ Exaggerated response (mild to
moderate hypertonia)
4+ Sustained responses (severe
hypertonia)

Sig: of affected, usually signifies brainstem

affectation or individual cranial nerve is
affected, may manifest as central or
peripheral lesion
Pathological Reflexes

ASHWORTH SCALE for Spasticity Grading

Grade
0
1

Description
No ms. tone
Slight in ms. tone,
manifested by a catch &
release or by min resistance
at the end of the ROM when
the affected part(s) is moved
Or

1+

3
4

Slight in ms. tone,

manifested by a catch,
followed by min resistance
throughout the remainder
(less than half) of the ROM
More marked increase in ms.
tone through most of the
ROM, but affected part(s)
easily moved
Considerable increased in
ms. tone, passive movement
difficult
Affected part rigid in flexion
and extension

Cranial Nerve Testing

CN
I
II
III, IV, VI
V
expression
VII
expression
VIII
IX, X
XI
XII

Result of Test
Pt. can smell
Intact light reflex
Intact conjugate eye movement
Intact corneal reflex/ facial
Functional ms. of facial
Pt. can hear
Intact gag reflex
Normal trapezius/ SCM strength
Pt. has (N) articulation

Initial Evaluation-LORMA

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e.g (+) clonus on (R) LE

sig. hyperactive stretch reflexes
(+) Babinski (some book suggest a (+) or
(-) extensor
plantar response instead of Babinski
sig. corticospinal tract affectation
or UMNL lesion
Developmental Reflexes
Test 4 levels of reflex development
e.g. (-) grasp reflex on (B) feet and
hands
(+) ATNR
(-) protective extension in sitting
Sig. Pt. is in brainstem level of
reflex
development
Coordination Testing
Non-Equilibrium
Test
Finger to finger
Pronation/
supination
Hand tapping

(L)
4
4
4

(R)
4
4
4

*Select test appropriate for pt. & case

Equilibrium
Test
Standing feet
together
Tandem walking
Walk on toes

Grade
3
3
3

Legend for grading:

4
normal performance
3
movement accomplished with slight
difficulty
2
moderate difficulty, movt, arrhythmic
performance, deteriorates with inc.
speed
1
severe difficulty, very arrhythmic,
unsteady,
oscillations, extrenous movt

unable to accomplish task

ANTHROPOMETRIC MEASUREMENT
Leg Length Measurement
Landmark
(L)
(R) Diff
TLLM
ASIS to medial
malleolus
ALLM
Umbilicus or
xiphoid to
medial
malleolus
Sig. TLL discrepancy 2 to bone shortening
ALL discrepancy 2 to pelvic obliquity,
contracture
Muscle Bulk Measurement
Landmark
(L)
(R)
Get bulkiest part
from a designated
landmark
e.g. 5 fr acromion
process

Before
dipping

Vol
displaced

After
dipping

(L)
(R)

Limb Girth Measurement

For atrophy of limbs

Landmark
Add 2 frm 1 bony
landmark
sequentially until a
next bony landmark
is reached
Sig. edema
Swelling

(L)

(R)

Diff

POSTURAL ASSESSMENT
Taken in _____ view (choose best view that
will show deviation)
e.g taken in standing position, ant view
- head in midline
- shoulders level
Initial Evaluation-LORMA

equal carrying angle

ASIS level
knees level
malleoli level
lateral view
-head forward
- shoulders rounded
- increased thoracic kyphosis
- flattened lumbar lordosis
- hips slightly flexed
- knees slightly flexed
sig. compensatory posture to facilitate
breathing
GAIT ASSESSMENT
Rancho Los Amigos

Diff

Sig. atrophy 2 to denervation, disuse

*For atrophy of hands/feet, use
volumetric
measurement.
Vol. of H2O

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HS
FF
MS
HO
TO
Accelerati
on
Midswing
Decelerati
on

hip
(N), -

knee

ankle

Note: data correlates the amt of motion

taking place at joint with that of (N) values
(note flexion, extension,etc)
-Stance phase time- _____ & laterality
-Swing phase time- ______ & laterality
-Trunk rotation: arm swing
-Cadence
-Step length, stride length
Sig. type of gait that pt. exhibits
FUNCTIONAL ASSESSMENT
FIM LEVELS
No Helper
7- Complete independence
6- Modified independence
Helper-Modified dependence
5- Supervision (subject 100%)
4- Min. asst (75%)
3- Mod. Asst (50%)
Helper-Complete dependence
2- Max. Asst (25%)
1- Total Asst or not testable (less than 25%)
ADL

GRADE

Self care

Feeding

Grooming

Bathing

Upper Garment
Dressing

Lower Garment
Dressing
Sphincter Control

Bladder Mx

Bowel Mx
Mobility

Bed mobility

Chair mobility

Toileting

Transfer

ADL
Locomotion

Gait

Expression
Communication

Comprehension

Expression
Social Cognition

Social Interaction

Memory

Problem Solving

GRADE 4: Full thickness skin loss with

extensive destruction and necrosis extending
to underlying tissue.

2
2
2
2
2

STUMP ASSESSMENT
- Shape, length, type, calculate % of
stump to classify
- Type of closure used (fish mouth or
post flap)
- Is skin mobile or adherent tissues
- Presence of neuroma

2
2
2
2
2
2

ELECTRODIAGNOSIS
(for PNI)
- Perform SDC or other tests
( impression will be given on A part of
the note)
- For cardiac cases, please include
assessment & endurance testing.

GRADE
7
7

Assessment

7
7

DIAGNOSIS:
PT IMPRESSION/ REHAB POTENTIAL
Based on Objective Findings
Functional Limitations
e.g stage 3- Bobath Stages of Recovery

7
7
7

sig.
Wound Assessment
- Shape
- Size
- Depth
- Odor
- Color- scar, granulation tissue
- If pressure sore, note the grade

Problem List

Pressure Sore Grading

GRADE 1: Discolouration of intact skin not
affected by light finger pressure (nonblanching erythema)
This may be difficult to identify in darkly
pigmented skin
GRADE 2: Partial-thickness skin loss or
damage involving epidermis and/or dermis.
The pressure ulcer is superficial and presents
clinically as an abrasion, blister or shallow
crater.
GRADE 3: Full thickness skin loss involving
damage of subcutaneous tissue but not
extending to the underlying fascia.
The pressure ulcer presents clinically as a
deep crater with or without undermining of
adjacent tissue.

Note: short, measureable, accurate, realistic,

time bound

Initial Evaluation-LORMA

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LTG (# of
tx/week) how
many session

STG(# of
tx/week) how
many session

*from most
to least
priority
*all problem

Plan
Pt. will be seen ___x/week for _____ tx
sessions
- Enumerate Mx given
*Modalities first before exercises
*GIVE COMPLETE PARAMETERS FOR
EACH
- Home/ Ward Instructions
- Suggested Mx
- PT instructions to pt. e.g energy
conservation technique, proper body
mechanics

Swelling

Comes on soon after injury ~ blood

Comes on after 8 to 24 hours ~ synovial
Boggy, spongy feeling ~ synovial
Harder, tense feeling with warmth ~ blood
Tough, dry ~ callus
Leathery thickening ~ chronic
Soft, fluctuating ~ acute
Hard ~ bone
Thick, slow-moving ~ pitting edema

Cramping, dull, aching

Muscle
Dull, aching
Ligament, joint capsule
Sharp, shooting
Nerve root
Sharp, bright, lightning-like Nerve
Burning, pressure-like, stinging,
Sympathetic nerve
aching
Deep, nagging, dull
Bone
Sharp, severe, intolerable
Fracture
Throbbing, diffuse
Vasculature

Initial Evaluation-LORMA

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