Dr Nikhil chugh(P.T) B.P.T, M.P.

T(SPORTS)

Dr. Manjeet kaur(P.T) B.P.T , M.P.T(NEURO)

Friends Physiotherapy & Neuro Rehabilitation Centre CEREBRAL PALSY ASSESSMENT

Date of first visit

NAME: AGE: ADDRESS: INFORMANT: 1. mother DIAGNOSIS: TYPE FATHERS NAME: AGE OCCUPATION EDUCATION 2.father GENDER CONTACT NO. 3.other caregiver

MOTHERS NAME AGE OCCUPATION EDUCATION

PRIMARY CARE GIVER HISTORY OF SIMILAR ILLNESS OR ANY OTHER RELEVENT ILLNESS:

AGE OF MOTHER AT CHILDS BIRTH(yrs):

BIRTH HISTORY: 1.gravida

2.parity

3.abortions

ANTENATAL ILLNESS(MALNUTRITION,EXCESSIVE VOMITING,FEVER,CHICKEN POX,MUMPS)

GENERAL MEASLES DIABETESE ACCIDENT OR INJURY PSYCHOLOGICAL TRAUMA HYPERTENSION ANY HORMONALPROBLEM DRUG/ALCOHOL/SMOKING IRRADIATION

FOETAL MOVEMENTS: 1. NORMAL NATAL: 1.PREMATURE 2.FULL TERM 3.POSTMATURE 4.NOT KNOWN 2.SLUGGISH 3.EXCESSIVE 4.NOT KNOWN

NO. OF FETUSESGESTATIONAL AGEPLACE OF DELIVERY1.HOME 2.PRIMARY CARE CENTRE 3.SECONDARY 4.TERT

TYPE OF DELIVERY1. NORMAL 2.FORCEPS 3.BREECH 4.CAESARIAN 5.OTHERS DELIVERED BY1.MIDWIFE 2.NURSE 3.DOCTOR 4.UNTRAINED DAI 5.OTHER(SPECIFY)

TYPE OF LIQUOR1.MECONIUM STAINED 2.FOUL SMELLING 3.NORMAL 4.NOT KNOWN LABOUR HOURS1.KNOWN(SPECIFY) 2.NOT KNOWN

PRESENTATION1.VERTEX 2.BREECH 3.ANY OTHER 4.NOT KNOWN WAS CORD AROUND THE NECK1.YES(NO.OF TURNS) 2.NO 3.NOT KNOWN

ANY EXCESSIVE BLEEDING AFTER DELIVERY1.YES 2.NO 3.NOT KNOWN

RESUSCITATIVE EFFORTS NEEDED1.YES 2.NO 3.NOT KNOWN

RH FACTORI.MOTHER: 1.POSITIVE 2.NEGATIVE 3.NOT KNOWN II.CHILD: 1.POSITIVE 2.NEGATIVE 3.NOT KNOWN

BIRTH WEIGHTBIRTH CRY1.GOOD 2.POOR 3.ABSENT 4.NOT KNOWN

WERE THERE ANY SIGN OF- 1.YES 2.NO 3.NOT KNOWN

JAUNDICE CYANOSIS SEPTAECEMIA INFECTION CONVULSIONS HYPOGLYCEMIA RESPIRATORY DISTRESS APATHY

DESCRIBE-(IF,ANY) -

COLOUR OF THE CHILD1.YELLOW 2.BLUE 3.PALE 4.PINK 5.NOT KNOWN

APGAR SCORE1.KNOWN 2.NOT KNOWN 3.AT BIRTH /10 4.AT 5MINS /10

IMMUNIZATION1.NOT DONE 2.PARTIAL 3.COMPLETE 4.NOT KNOWN

POST NATAL- 1.YES .2NO 3.NOT KNOWN IF PRESENT DESCRIBE:

MEASLES CHICKEN POX WHOOPING COUGH TUBERCULOSIS GERMAN MEASLES PNEUMONIA HIGH FEVER TRAUMA MUMPS TYPHOID CONVULSIONS

MENINGITIS ENCEPHALITIS JAUNDICE

EXCESSIVE CRYING FEEDING PROBLEM HEART PROBLEM

UNCONCIOUSNESS CHEST INFECTION CONGENITAL ANOMALIES

FREQUENT SORE THROAT OR COUGH

PAST HISTORY-

CHIEF COMPLAINTS1. DELAYED NUKE STONES 2.SEIZURES 3.WALKING DIFFICULTIES

MOST BOTHERSOME COMPLAINT1.DELAYED MILESTONES 2.SEIZURES 3.WAKING DIFFICULTY ASSOCIATED SYMPTOMS- 1.YES 2.NO HEARING VISION ADHD SKELETAL SYSTEM DROOLING OF SALIVA SPEECH MENTAL RETARDATION ANY OTHER

SEIZURES1.PARTIAL 2.GENERALISED 3.PARTIAL> GENERALISED 4.ABSENT 5.MULTIPLE TYPES(DESCRIBE)

H/O EARLY HAND PREFERENCE1.RIGHT 2.LEFT 3.ABSENT 4.NOT KNOWN

MEDICAL EXAMINATION Anthropometry: Weight in gms height length in cms head circumference

HIGHER FUNCTION: INTRACTION WITH EXAMINER 1.GOOD 2.FAIR 3.POOR INTREST IN SURROUNDINGS 1. GOOD 2.FAIR 3.POOR OVER ALL ACTIVITIES 1. GOOD 2.FAIR 3.POOR

INTELLIGENCE QUOTIENT1.NORMAL 2.EDUCABLE(80-75) 3.EDUCABLY SUB NORMAL(60-55) 4.TRAINABLE(54-40) 5.NON TRAINABLE(BELOW 40)

EXACT IQSCHOOLING: 1.REGULAR 2.SPECIAL SCHOOL 3.HOME EDUCATION 4.DROP OUT 5.NO FORMAL EDUCATION

SPEECH AND ARTICULATION1.APPROPRIATE FOR AGE 2.DELAYED

HEARING1.NORMAL 2.ABNORMAL 3.CANNOT BE ASCERTAINED

VISION- 1.PRESENT 2.ABSENT TRACKING FIXATION SQUINT ABNORMALITY IN FUNDUS INVOLUNTARY EYE MOVEMENTS DESCRIBE THE ABNORMALITY

CRANIAL NERVE ABNORMALITY-1.PRESENT 2.ABSENT IF PRESENT,DESCRIBE

INVOLUNTARY MOVEMENTS1.PRESENT TYPE: CHOREA CHOREATHETOSIS MYOCLONUS DYSTONIA ATHETOSIS MIXED 2.ABSENT

POSTURE1.NORMAL SUPINE 2.ABNORMAL SITTING STANDING

GAIT- 1.POSSIBLE 2.NOT POSSIBLE I.HOP II.TANDEM WALK III.TOE WALK IV.HEELWALK

RISE FROM SQUATTINGINDEPENDENT WITH ASSISTANCE ABSENT

SGAIT PATTERN1.NON AMBULANT 5.MIXED(SPECIFY) 2.SPASTIC 6.NORMAL 3.ATAXIC 4.DYSTONIC

HAND FUNCTIONS1.ABSENT 2.POOR 3.FAIR 4.GOOD

GRIP: CYLINDRICAL OPPOSITION PINCH RELEASE

SPHERICAL

CONICAL

APPLIANCES/AIDS- 1.YES 2.NO (DESCRIBE,IF ANY)

MOTOR FUNCTIONS: JOINT ROM:

DEFORMITY: PRESENT/ABSENT

CONTRACTURE:PRESENT/ABSENT

TONE: NORMAL/FLACCID/SPASTIC/RIGID

VOLUNTARY CONTROL: ABSENT/IMPAIRED/ NORMAL

SHORTENING: PRESENT/ABSENT

WASTING: PRESENT/ABSENT

REFLEXES- 1.PRESENT 2.ABSENT I. PRIMITIVE REFLEX: MORO REFLEX SUCKING REFLEX GRASP REFLEX ROOTING REFLEX

II.SPINAL LEVEL REFLEXES: FLEXOR WITHDRAWL EXTENSOR THRUST CROSSED EXTENSOR RESPONSE

III.BRAIN STEM LEVEL REFLEXES: ATNR STNR TONIC LABRYINTHINE REFLEX ASSOCIATED REACTIONS

IV. MID BRAIN LEVEL REFLEXES: NECK RIGHTING ACTION ON BODY BODY ACTING ON BODY LABRYINTHINE ACTING ON BODY

V.STRETCH REFLEXES: 1.ABSENT 2.+ BICEPS 3.++ 4.+++ 5.++++

TRICEPS SUPINATOR KNEE ANKLE

VI.SUPERFICIAL REFLEXES: 1.NORMAL 2.ABNORMAL ABDOMINAL CREMASTSERIC PLANTAR

CEREBELLAR SYSTEM: 1.YES 2.NO 3.Cannot be assessed Finger Nose incoordination Heel knee Incoordination

BOWEL: 1.REGULAR 3.CONTINUOUS INCONTINENCE 2.INTERMITTENT INCONTINENCE 4.CONSTIPATION

BLADDER: 1.CONTINENCE 3.INTERMITTENT DRIBBLING 2.NOCTURNAL ENURESIS 4.CONTINUOUS DRIBBLING

MEDICATION:1.YES 2.NO ANTICONVULSANT DRUGS DRUG FOR ADHD ANTI SPASTICITY DRUGS OTHERS DRUG FOR RIGIDITY

SURGERY DONE: RHIZOTOMY TENOTOMY TENDON LENGTHENING OTHERS

INVESTIGATIONS DONE:

TREATMENT PLAN:

GOALS OF THE TREATMENT-

SHORT TERM GOALS

LONG TERM GOALS

TREATMENT PROTOCOL-

DEVELOPMENTAL MILESTONES0.NOT KNOWN 1.NOT ATTAINED 2.ATTAINED(SPECIFY MONTHS) GROSS MOTOR Neck Control (3mnths) Rolling (4-5mnths) Crawling (9mnths) Sitting w/o support(6mnths) Standing w/o support(10mnths) FINE MOTOR Hand regard (2mnths) Reach for object (4mnths) Transfer object hand to hand (6mnths) Pincer grasp (9mnths) Release object (12mnths) SOCIAL Social smile (1mnths) Recognizing mother (2mnths) Mirror play (6mnths) Stranger anxiety (9mnths) Indicates desires by pointing (9mnths) Imitates action, comes when called (12mnths) Plays with other children(24mnths) Self feeding, tell names(2.5yrs) Ground play (3yrs) Plays competitive games & helps household(5yrs) LANGUAGE Alert to sound (1-2 month) Babbling (6 mnth) Respond to call of name (9 mnth) Non specific dada mama (10 month) Follow simple commands (1yrs) Identify parts of body (18 month) Form sentences, 23 words (24mnth) Uses 3 word sentences (3yrs) Knows colours (4yrs) Asks what a word means (5yrs)

Walking w/o supp. Building blocks (12mnths) (15mnths) Climbing (15mnths) Running (18mnths) Walking up &down Steps(24mnths) Rides tricycle (3yrs) Hops, skips (4yrs) Jumps over obstacles(5yrs) Turns 2-3pages (18mnths) Drinks from cup (24mnths) Dress& undress partially(3yrs) Buttons fully, catches ball(4yrs)