PAEDIATRIC ASSESSMENT FORMAT
Demographic Data
Name:
Gender:
D.O.B:
[Link] O.P No:
Address and Mobile No:
Age:
• Chronological Age:
• Corrected Age:
40 (mean gestational age) - Gestational age = X Chronological age - X =
corrected age
• Gestational Age:
Preterm/Premature: <35 weeks
Full term >35 weeks
NEGLER'S FORMULA: Expected date of delivery=LMD+9months±7days:
Date of Admission:
Date of Assessment:
Care giver Name:
Parents Occupation:
Hand dominance:
Informant:
Growth Parameters At Birth At Present
Weight (kg)
Height (cm)
Head Circumference
Chest Circumference
BMI
Details of Marriage: - Consanguineous/ Non- Consanguineous marriage
CHIEF COMPLAINTS:
HISTORY
Prenatal/ Antenatal History
•· Planned or Unplanned Pregnancy
• Month of Pregnancy Detection
• Mode of Detection
• How was the Antenatal check-up?
• In which month Ultrasound check-up was done
• Any Abnormality noted in USG
• In which moth mother felt Quickening
• Regular Folic Acid Intake
• Weight Gain/Loss during Pregnancy
• Exposure to drugs and toxins
• Exposure to X-ray
• Alcohol/Smoking
• Gestational Diabetes
• Gestational HTN
• Thyroid
• Epilepsy
• History of Vomiting
• Any Hospital Admission during Pregnancy and Why
• Vaccination during pregnancy: TT- l y TT-2 TT- Booster
2
Natal History
• Duration of Labor
• Whether it is Natural or Induced Labor
• Mode of Delivery: Normal/ C-section
• Birth Cry of Baby: Strong/ Week · immediate/ Delay
APGAR Scale Score
Score 0 1 2
Appearance Bluish Trunk-Pink, Pink
Extremity- Blue
Pulse No Pulse <100 >100
Grimance No Response Taking away the Crying
Extremity
Activity No Movement Partial tone Normal
Respiration No movement in Breathing- Thorax goes up
Thorax Thorax shallow and down
gasping
Total score= 10
>7 Normal
<7 Abnormal
Score taken at 1 min: 5min: 10min:
• Feeding
• Any Infection ~
• Baby was shifted from Mother to NICU and Why
• Condition during discharge
Postnatal history
Post-natal history of mother
• Any infection (jaundice, herpes, rubella etc.)
• Breast fed (YI N)
• Any other complications Post-natal history of child
• Whether the infant was floppy/ spastic
3
• Head injury/trauma
• Epilepsy
• Fever I Hydrocephalus
• Neonatal jaundice
• Hypoglycaemia • Immunization
• Age of the child when disability was noticed
OBG History
Age of father Age of mother
GPLAD
G- How many times Mother Conceived
P- How many times Pregnancy carried till 28 weeks
L- No of Live Baby
A-No of Abortion
D-No of Death
Surgical History
• Any surgery is done and why and which age
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Developmental History (Mile stones)
Gross Motor
Milestone Reference range Concern if not Baby achieved
(months) achieved by - at
{months)
Head lifting 3-4 4-5
Rolling over 4-7 8-9
Sitting without 6-9 10+
support
Creep/Crawl/Cruise 9-10 12
Walking 11-12 15+
Walking Up 24-26 36
&Down stair case
Tri-cycling 35-38 35-38
Fine Motor
Milestone Reference Concern if not Baby achieved
range(months) achieved by - at
(months)
Hand un-fisting/ 3-4 4-5
touches object
Mid line activity 4-5 6+
Voluntary release 11-13 15+
Scribbles/ Feeds 14-16 18+
self with spoon/
Stacks 3 cubes
Tum book pages/ 23-25 30+
remove socks &
shoes
Draws circle 35-37 48+
Buttons cloth/ 46-50 60+
catches ball
5
Language /auditory/vision Milestone
Milestone Reference range Concern if not Baby achieved at
(months) achieved by -
(months)
Cooing 0-3 3-4
Babbles/ ba, da 3-6 7+
Tries to imitate/ 6-9 10+
Tries to vocalize
emotional
satisfaction
/Dissatisfaction
Able to speak few 9-18 20+
words / Imitate
Can speak short 18-30 31+
sentences. can
name common
fruits & animals
Startle with loud 3-6 7+
noise/ Awakens
with clap
Recognizes 6-9 10+
mothers
sound/when
spoken listens to
sound 3-6 7+
Turns head
towards sound
source
Looks up when 9-18 20+
called, -
understands
simple commands
Response to 18-30 32+
complex
commands
6
Social/emotional /behavioural Milestones
Milestone Reference range Concern if not Baby achieved at
(months) achieved by -
(months)
Social smile 6 Weeks 3+
Regards face. ·, 1 2+
Recognize 2 3+
parents
Recognize 6 8+
strangers
Waves bye bye 9-10 12+
Cognitive milestones
Milestone Reference range Baby achieved
(months) at
Brings object in hand to 4 months
mouth
Pats a mirror 7 months
Removes cover from 8 months
favourite toy
Explores object in hand 9 months
with interest
Waves good 10 months
bye/Removes small toy
from under cup
Puts comb to hair/Looks 12 months
for object out of
sight/Recognises ‘NO’
Points to distant 18 months
interesting objects/Obeys
simple instructions/Points
to body parts
Refers to self by 2 years
name/Actively curious
with no sense of
damage/Make believe
play
Understands up,down, 21/2 years
sideways,200+ words
7
Matches colours, mainly 3 years
real and yellow
Appreciates 4 years
past,present,future/Counts
to 20
Act out stories 5 years
Begins to understand 6 years
rules & negotiation
OBSERVATION
1. Observe the child for behaviour, playfulness, fatigue, communication, eye
contact, following commands & attention span
2. Involuntary movements
3. Preferable position/ body attitude
A) Supine Line
• Head is in midline position or not
• Baby is able to trace the object or not
• Check whether the baby is able to do bilateral movement of hand
• Check whether the baby is able to attempt turning
• Check bilateral folding activities (kicking) for lower limb
B) Prone Line
• Neck extension
• Check for sustained neck extension or not
• Check baby is able tq go to supine
• Baby is able to turn on tummy
• Lower limb activities
C) Sitting
• When the baby is made to sit position of sitting-L3 sitting/ Ls sitting
• Observe bilateral midline activities of limbs
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D) Standing
• When baby is made to stand- independent standing I supported standing
• Activities bilateral midline observation
• Check whether baby can maintain complete foot standing
• Check for knee break-because of more amount of flexor withdrawal reflex
Associated Problems (if any)
• MR
• Convulsions
• Any H/O of surgery/ medical or PT treatment
•Visual impairment
• Hearing impairment
• Speech disorder
• Sensory disorders
• Meningeal signs
• Feeding problems (feeding, drooling, swallowing etc )
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EXAMINATIONS
1. Neonatal Reflex examination
A) Spinal level / Onset Integration Comment
Primitive
Sucking & Rooting At Birth 6 months
Flexion withdrawal 28 weeks of 1-2 months
gestation
Crossed extension 28 weeks of 1-2 months
gestation
Traction 28 weeks of 2-5 months
gestation
Moro's 28 weeks of 5-6 months
gestation
Startle Birth Persists
Palmar grasp Birth 4-6 months
Plantar grasp 28 weeks of 9 months
gestation
B) Brain Onset Integration Comments
stem/Tonic
ATNR At Birth 4-6 months
STNR 4-6 months 8 -12 months
TLR At Birth 6 months
Positive supporting At Birth 6 months
Associated - Birth to 3 8 9 years
reactions months
C) Midbrain / Onset Integration Comments
Cortical
NOB Birth 4-6 months
BOB Birth 10 months
Protective extension 4-6 months Persists
(arm)
Protective extension 6-9 months Persists
(Legs)
Equilibrium 7-8 months ( Persists
reactions sitting)
12-21 months
(Standing)
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2. Higher mental function & cranial nerves examinations:
3. Sensory examination/ short sensory profile:
4. Motor examinations:
Muscle tone:
0 - No response (flaccid)
l + - Decreased response (Hypotonia)
2+- Normal
3+ - exaggerated response (Mild to moderate hypertonia)
4+ - sustained response (Severe hypertonia)
(If the grade is 3+ or more then check for spasticity [Modified Ashworth Scale]
Modified Ashworth scale for grading spasticity
Scoring Response of the patient
0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a catch & release
or by minimal resistance at the end of the ROM when the
affected part(s) is moved inflexion or extension
1+ Slight increase in muscle tone, manifested by a catch, followed
by minimal resistance throughout the remainder (less than
half) of the ROM
2 More marked increase in muscle tone through most of the
range of motion, but affected part easily moved
3 Considerable increase in muscle tone, passive movement
difficult
4 Affected part rigid in flexion or extension
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Reflex examination:
0 = Absent
+ = Hyporeflexia
++=Normal
+++ =Exaggerated
++++=Clonus / Hyperreflexia
ROM
Upper extremity evaluation
Strength ROM ROM Motion Normal Tone
MMT (0- (Rt.) (Lt.) (MAS)
5) OR
VMC
Rt. Lt. A P A P
Extension 45
Flexion 180
Abduction 0-180
Adduction 180-0
Lat. Rot. 90
Med. Rot. 70
Extension 145-0
Flexion 0-145
Supination 90
Pronation 90
Extension 70
Flexion 80
UD 45
RD 20
Any tightness or deformities:
Impression:
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Lower extremity evaluation
Strength ROM ROM Motion Normal Tone
MMT (0- (Rt.) (Lt.) (MAS)
5) OR
VMC
Rt. Lt. A P A P
Extension 10
Flexion 125
Abduction 45
Adduction 45-0
Lat. Rot. 45
Med. Rot. 45
Extension 140-0
Flexion 0-140
PF 45
DF 20
Inversion 40
Eversion 20
Plantar Reflex
Any tightness or deformities:
Impression:
Muscle strength
Voluntary Motor Control (VMC) GRADING
1+ :- Gravity eliminated plane with 1/3rd movement possible.
1++ :- Gravity eliminated plane with 2/3rd movement possible
1+++:- Gravity eliminated plane with full range of motion.
2+ :- Against gravity 1/3rd movement possible.
2++ :- Against gravity 2/3rd movement possible.
2+++ :- Against gravity full range possible.
3+ :- Against gravity with resistance 1/3rd movement possible.
3++ :- Against gravity with resistance 2/3rd movement possible.
3+++ :- Against gravity with resistance full movement possible.
4 :- Skilled movement
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Spine examination
Spine examination Restrictions (YIN) if .
~_; yes then specify
[Link]
[Link]
3. Lateral flexion a) To right
b) To left
[Link] a) To right
b) To left
Any scoliosis ( convex) or Kyphosis:
Muscle girth:
LimbLength:
Posture examination (AP/PA/Rt. & Lt. lateral view)
Supine: .
Prone:
Sitting:
Standing:
Balance examination :( paediatric balance scale)
Gait (Observation):
5. Functional evaluation: GMFM88/GMFM66, TCMS, INFANIB
6. Differential diagnosis:
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7. Investigations:
8. Interdepartmental Diagnosis:
9. Physiotherapy Diagnosis:
Problem List :( ICF CHECK LIST)
Treatment goals:
Short term goals
Long term goals
Treatment strategies /Management:
Prognosis & follow up:
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Appendix
Head circumference ranges (Cm)
Birth 30 - 35.5
Till 3 months Increases 2 cm/month
3months- 1 year Increase of 2cm/3 months
1-3 years 1cm /6 months
3-5 years 1cm/yr
5yrs 48.1-51.5 cm.
• Adult head size is achieved within 5 -6 years.
Height ranges (Cm)
Birth 50 cm
Gain during 1st year 25 cm
Gain during 2nd year 12.5 cm
Gain during 3rd year 7.5- 10
Gain during 3-12 years 5-7.5 cm /year
Adolescence 8cm/year for girls
10cm/ year for boys
Weight velocity
Birth weight 2.5-4.5 kg
0-4 months Increases 1 kg /month
5-8 months Increases 0.75kg /month
9-12 months Increases 0.5kg / month
1-2 years Increases 3 kg /year
3-12 years Increases 2kg /year
12-18 years Increases 5-6 kg /year
1.5-2.5-LBW, 1-1.5- VLBW
BMI
Sever underweight <13
Underweight: below the 5th percentile <15
Normal weight: 5th-84th percentile 15-21
Overweight: 85th 94th percentile 22-25
Obesity: ≥95th percentile >26
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GMFCS
To identify the level of cerebral palsy
Level 1- Walks without limitations
Level 2- Walks within limitations
Level 3- Walks using a hand-held mobility device
Level 4- Self mobility with limitations; may use powered mobility
Level 5- Transported in a manual wheelchair
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