Neuro physiotherapy assessment sheet generator
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Physiotherapy Department
Neurological
Assessment
Assessment
| Patient Name | Age / Sex | ||
| UHID / MRN | Date of Assessment | ||
| Diagnosis | |||
| Date of Onset | Referring Physician | ||
| Occupation | Dominant Hand | ||
1Chief Complaint & History of Present Illness
2Past Medical / Surgical History
Hypertension
Diabetes Mellitus
Cardiac disease
Previous CVA / TIA
Seizure disorder
Smoking
Alcohol use
Prior surgery
Other
3Higher Mental Functions
Glasgow Coma Scale
| Eye Opening (/4) | Verbal Response (/5) | Motor Response (/6) | Total (/15) |
|---|---|---|---|
Orientation & Memory
Oriented to Time
Oriented to Place
Oriented to Person
Immediate Memory Intact
Recent Memory Intact
Remote Memory Intact
Speech & Language
Comprehension Normal
Expression Normal
Fluent
Dysarthria
Aphasia
4Cranial Nerve Examination
| Nerve | Function Tested | Normal | Abnormal | Notes |
|---|---|---|---|---|
| I – Olfactory | Sense of smell | |||
| II – Optic | Visual acuity & fields | |||
| III, IV, VI | Eye movements, pupils, ptosis | |||
| V – Trigeminal | Facial sensation, jaw power, corneal reflex | |||
| VII – Facial | Facial expression & symmetry | |||
| VIII – Vestibulocochlear | Hearing & balance | |||
| IX, X | Swallowing, gag reflex, palate/uvula | |||
| XI – Accessory | Shoulder shrug, SCM strength | |||
| XII – Hypoglossal | Tongue movement / protrusion |
5Motor System
Muscle Bulk
Right UL Normal
Right UL Wasted
Left UL Normal
Left UL Wasted
Right LL Normal
Right LL Wasted
Left LL Normal
Left LL Wasted
Tone — Modified Ashworth Scale
0 No increase 1 Slight, catch & release 1+ Slight, catch + min. resistance 2 Marked, most of ROM 3 Considerable, passive movement difficult 4 Rigid
| Joint / Muscle Group | Right | Left |
|---|---|---|
| Shoulder | ||
| Elbow | ||
| Wrist | ||
| Hip | ||
| Knee | ||
| Ankle |
Power — MRC Grading (0–5)
0 No contraction 1 Flicker/trace 2 Active, gravity eliminated 3 Active against gravity 4 Active against resistance 5 Normal power
| Muscle Group | Right | Left |
|---|---|---|
| Upper Limb | ||
| Shoulder Flexors / Abductors | ||
| Elbow Flexors / Extensors | ||
| Wrist Flexors / Extensors | ||
| Hand Grip | ||
| Lower Limb | ||
| Hip Flexors / Extensors / Abductors | ||
| Knee Flexors / Extensors | ||
| Ankle Dorsi / Plantarflexors | ||
Deep Tendon Reflexes (0–4+)
0 Absent 1+ Diminished 2+ Normal 3+ Brisk 4+ Clonus present
| Reflex | Right | Left |
|---|---|---|
| Biceps (C5–C6) | ||
| Triceps (C7–C8) | ||
| Supinator (C5–C6) | ||
| Knee (L3–L4) | ||
| Ankle (S1–S2) |
Superficial Reflexes, Plantar Response & Clonus
Plantar R: Flexor
Plantar R: Extensor
Plantar L: Flexor
Plantar L: Extensor
Abdominal Reflex R Present
Abdominal Reflex L Present
Ankle Clonus R
Ankle Clonus L
Patellar Clonus R
Patellar Clonus L
Involuntary Movements
None
Tremor
Chorea
Athetosis
Dystonia
Fasciculations
6Sensory System
| Modality | Right UL | Right LL | Left UL | Left LL |
|---|---|---|---|---|
| Light Touch | ||||
| Pain / Pinprick | ||||
| Temperature | ||||
| Vibration | ||||
| Proprioception (JPS) | ||||
| 2-Point Discrimination |
Romberg's Test Positive
Romberg's Test Negative
7Cerebellar Function
| Test | Right | Left | Notes |
|---|---|---|---|
| Finger-to-Nose | |||
| Heel-to-Shin | |||
| Dysdiadochokinesia | |||
| Rebound Phenomenon | |||
| Nystagmus | |||
| Tandem Gait | |||
8Balance & Gait Assessment
Static / Dynamic Balance
Sitting Balance Normal
Sitting Balance Impaired
Standing (EO) Normal
Standing (EO) Impaired
Standing (EC) Normal
Standing (EC) Impaired
Ambulation Status
Independent
Independent with device
Assisted (1 person)
Assisted (2 person)
Non-ambulatory
Assistive Device
None
Cane
Quad Cane
Walker
Wheelchair
AFO / Orthosis
Other
Gait Deviations
Foot Drop
Circumduction
Steppage
Ataxic
Hemiplegic
Antalgic
Trendelenburg
Scissoring
Festinating
Wide-based
9Standardized Outcome Measures
| Scale | Score | Notes |
|---|---|---|
| Berg Balance Scale (/56) | ||
| Barthel Index — ADL (/100) | ||
| Modified Rankin Scale (0–6) | ||
| Functional Ambulation Category (0–5) | ||
| Timed Up & Go (sec) | ||
| 10-Metre Walk Test (m/s) | ||
| Other |
10Clinical Impression / Assessment Summary
11aShort-Term Goals
11bLong-Term Goals
12Treatment Plan
NDT / Bobath
PNF
Task-Specific Training
Gait Training
Balance Training
Strengthening
ROM / Stretching
Electrical Stimulation
Patient / Caregiver Education
Other