SRM COLLEGE OF PHYSIOTHERAPY
SRM UNIVERSITY
ASSESSMENT CHART FOR MUSCULAR DYSTROPHY CENTER
CHILD NAME:
FATHER NAME:
MOTHER NAME:
AGE/SEX:
ADDRESS:
PHONE NUMBER:
MODE OF COMMUNICATION:
HAND DOMINANCE:
CHIEF COMPLAINTS:
HISTORY OF PRESENT ILLNESS:
PAST MEDICAL/SURGICAL HISTORY:
FAMILY HISTORY:
GENETIC HISTORY:
MILESTONE HISTORY:
SOCIO ECONOMIC STATUS:
ON OBSERVATION:
BODY BUILT:
POSTURE:
ATTITUDE OF LIMB:
TROPICAL CHANGES:
PSEUDOHYPERTROPHY OF MUSCLES:
OEDEMA/SWEELING:
LOCOMOTION:
EXTERNAL APPLIANCES:
GOWERS SIGN:
ON EXAMINATIONS:
HIGHER MENTAL FUNCTIONS:
CONSCIOUSNESS:
ORIENTATIONS:
MEMORY:
ATTENTION:
CALCULATIONS:
EMOTION:
SPEECH AND LANGUAGE:
IQ:
SENSORY ASSESSMENT:
SUPERFICIAL SENSATION:
DEEP SENSATION:
MOTOR ASSESSMENT:
TONE OF MUSCLE:
MUSCLE POWER CHART ATTACHED:
RANGE OF MOTION CHART ATTACHED:
REFLEXES:
MUSCLE GIRTH : RIGHT LEFT
BICEPS:
BRACHIORADIALIS:
MID THIGH:
MID CALF :
BLADDER AND BOWEL CONTROL:
GAIT ASSESSMENT:
POSTURE ASSESSMENT:
SITTING:
STANDING:
MOBILITY ASSESSMENT
• EQUIPMENT WHEELCHAIR: YES / NO
• ORTHOTHICS BREIF DESCRIPTION: YES / NO
SLEEP ASSESSMENT:
CARDIO RESPIRATORY ASSESSMENT:
RESPIRATORY RATE:
CHEST MEASUREMENT
• AXILLARY LEVEL
• NIPPLE LEVEL
• XIPHISTERNUM LEVEL
COUGHING EPISODE OF MEAL TIME:
DYSPNOEA:
ORTHOPNEA:
SHORTNESS OF BREATH:
RECURRENT CHEST INFECTION:
NASAL REGURGITATION:
ACCESSORY MUSCLE AT REST:
ABDOMINAL PARADOX:
CYNOSIS:
PAPPILO OEDEMA:
HYPO VENTILATION:
FUNCTIONAL ASSESSMENT
STAGE 1-DIAGNOSIS/EARLY STAGE
STAGE 2-YOUNG MOBILE
STAGE 3-GOING OFF FEET
STAGE 4-EARLY POWER CHAIR USER
STAGE 5-LONG TERMED POWERED CHAIR USER
STAGE 6-PALLATIVE PHASE
INVESTIGATION:
DNA REPORT INVESTIGATION:
CLINICAL IMPRESSION:
PROBLEM LIST:
GOALS:
NOTES:
MUSCLE POWER CHART
SHOULDER: RIGHT LEFT
FLEXORS:
EXTENSORS:
ABDUCTORS:
ADDUCTORS:
MEDIAL ROTATORS:
LATERAL ROTATORS:
ELBOW
FLEXORS:
EXTENSORS:
WRIST
FLEXORS:
EXTENSORS:
HAND GRIP :
SPINAL FLEXORS:
SPINAL EXTENSORS:
HIP
FLEXORS:
EXTENSORS:
ABDUCTORS:
ADDUCTORS:
KNEE RIGHT LEFT
FLEXORS:
EXTENSORS:
ANKLE
DORSIFLEXORS:
PLANTARFLEXORS:
RANGE OF MOTION
SHOULDER:
FLEXION:
EXTENSION
ABDUCTION:
ADDUCTION:
MEDIAL ROTATION:
LATERAL ROTATION:
ELBOW
FLEXION:
EXTENSION:
WRIST
FLEXION:
EXTENSION:
RIGHT LEFT
RADIAL DEVIATION:
ULNAR DEVIATION:
HIP
FLEXION:
EXTENSION :
ABDUCTION:
ADDUCTION:
KNEE
FLEXION:
EXTENSION:
ANKLE
DORSI FLEXION:
PLANTAR FLEXION: