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Physio Neuro Ax Template

This document contains a neurological assessment form for physiotherapy. It collects information about a patient's medical history, current symptoms and impairments, observations of cognition, sensation, coordination, strength, and other physical functions. The assessment evaluates areas like memory, speech, vision, reflexes, range of motion, balance, and gait. It concludes with a summary of impairments, clinical impression, goals agreed upon with the patient, and the proposed treatment plan.

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Hussain Lafta
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© © All Rights Reserved
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624 views8 pages

Physio Neuro Ax Template

This document contains a neurological assessment form for physiotherapy. It collects information about a patient's medical history, current symptoms and impairments, observations of cognition, sensation, coordination, strength, and other physical functions. The assessment evaluates areas like memory, speech, vision, reflexes, range of motion, balance, and gait. It concludes with a summary of impairments, clinical impression, goals agreed upon with the patient, and the proposed treatment plan.

Uploaded by

Hussain Lafta
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Physiotherapy Neurological Assessment Form

Name: DOB: Home: Date:


Subjective
PC:

HPC:

PMH:

DH:

FH:

SH:

Relevant investigations / Current Treatment Plan:

1
Observations & Initial presentation

Cognition:

Orientation
Time ☐ Place ☐ Person ☐

Memory
Normal ☐ Impaired ☐
STM impaired ☐
LTM impaired ☐
Concentration / attention problems ☐

Perception:
Normal ☐ Impaired ☐
Neglect ☐ ( L / R )
Inattention ☐ ( L / R )

Other……………………………………………………………………………

Speech:
Normal ☐ Impaired ☐
Dysphasic ☐ ( expressive / receptive )
Dysarthric ☐
Cerebellar / Ataxic ☐

Hearing:
Normal ☐ Impaired ☐
Hearing aid ☐
Other………………………………………………………………………………

Vision:
Normal ☐ Impaired ☐ Diplopia ☐ Nystagmus ☐
Glasses ☐ Hemianopia ☐

Other………………………………………………………………………………..

2
Skin Condition:
Normal ☐ Abnormal ☐
Details:…………………………………………………………………………….

Sensation:
Normal ☐ Abnormal ☐

Upper limb: Left:

Right:

Lower limb: Left:

Right:

Trunk:

Proprioception:
Normal ☐ Abnormal ☐

Details…………………………………………………….

Coordination:
Left Right
Upper limb: Finger/nose test ☐ Normal ☐ Normal
☐ Reduced ☐ Reduced
☐ Overshoots ☐ Overshoots

Dysdiadokinesis ☐ Normal ☐ Normal


☐ Reduced ☐ Reduced

Lower limb: Heel / Shin test ☐ Normal ☐ Normal


☐ Reduced ☐ Reduced

Alternate Heel / Toe ☐ Normal ☐ Normal


☐ Reduced ☐ Reduced

3
Body Chart

Posture:

Pain:

Tone:
Upper limb: Left:

Right:

Lower limb: Left:

4
Right:

Trunk:

Reflexes:

Biceps (C5,6) ……….


Brachioradialis (C6) ……….
Triceps (C7) ……….
Patella (L4) ……….
Achilles (S1) ……….

Involuntary Movement:

Tremor: ☐ N ☐ Y Details:…………………………………………………………

Clonus: ☐ N ☐ Y Details:…………………………………………………………

Chorea: ☐ N ☐ Y Details:…………………………………………………………

Associated Reactions: ☐ N ☐ Y Details:…………………………………………………………

Range of Movement:

Upper limb: Left:

Right:

Lower limb: Left:

Right:
5
Trunk:

Muscle strength:

Upper limb: Left:

Right:

Lower limb: Left:

Right:

Trunk:

Other Outcome Measures used:

6
Balance:

Sitting:

Standing:

Mobility:

Transfers:

Gait:

Summary of impairments:

Clinical impression:

7
Expectations of Treatment from Service User:

Agreed goals:

Treatment Plan:

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