Millennium Rehab, Inc.

• Enter the date of the evaluation:

  -- mm/dd/yy
  

• Patient's Information

  Name

  Date of Birth
  Sex	Male Female

• Please provide the following parent or guardian contact information:

  Name
  Work Phone
  Home Phone

• Facility:

  Armorel Public Schools Blytheville Public Schools Clay County Central Public Schools Craighead County Co-op Early Connections Fairview Elementary - Blytheville Schools Hoxie Public Schools Jonesboro Public Schools Manila Public Schools Millennium Rehab Outpatient NEA Co-op Osceola Public Schools Piggott Public Schools Rector Public Schools South Mississippi County Schools Walnut Ridge Head Start
  

• Enter patient's diagnosis applicable to therapy in the space provided below. (Remember, Developmental Delay is only acceptable through age of 7.)

  
  

• Background Information: (Medical history, reason for referral, behavior, etc.)

  
  

• Was child born prematurely? If yes, how many weeks?

  No Yes     
  

• Any complications at birth?

  
  

• Has child received previous skilled therapy?

  
  

• The following assessment tools were used during this evaluation:  (Scores provided on page 2)

  FIM - Functional Independence Measure
  Bruininks-Oseretsky Test of Motor Proficiency
  Peabody Developmental Motor Scales (PDMS2)
  Pediatric Evaluation of Disability Inventory
  The Test of Gross Motor Development

  
  

• Describe patient's Gait Analysis:

  
  

• Describe patient's Posture:

• Describe patient's Range of Motion as assessed through functional movements.  Is there a limitation greater than ten degrees?  How does the deficit limit function?:

• Left Lower Extremity Range of Motion:

  WFL - within functional limits HM - hypermobile MINL- minimal limitations MODL - moderate limitations SEVL - severe limitations

  
  

• Right Lower Extremity Range of Motion:

  WFL - within functional limits HM - hypermobile MINL- minimal limitations MODL - moderate limitations SEVL - severe limitations

   

• Left Upper Extremity Range of Motion:

  WFL - within functional limits HM - hypermobile MINL- minimal limitations MODL - moderate limitations SEVL - severe limitations

  
  

• Right Upper Extremity Range of Motion:

  WFL - within functional limits HM - hypermobile MINL- minimal limitations MODL - moderate limitations SEVL - severe limitations

   

• Using the Modified Ashworth Scale, rank patient's Muscle Tone as assessed through functional movements:

  0. No increase in muscle tone 1. Slight ^ in tone w/ catch & release or min resistance at end of range 2. As 2 but w/ min resistance through range following catch 3. More marked increase tone through ROM 4. Considerable increase in tone, passive movement difficult. 5. Affected part rigid

   

• Manual Muscle Test: A deficit is a muscle strength grade of fair (3/5) or below that impedes functional skills.

  Using the Medical Research Council (MRC) Score, rank patient's Strength as assessed through functional movements:

  0. No movement 1. Palpable contraction, no visible movement 2. Movement but only with gravity eliminated 3. Movement against gravity 4. Movement against resistance but weaker than normal 5. Normal power

• Transfer Skills: Document amount of assistance required to perform transfer, i.e., maximum, moderate, minimal assistance. A deficit is defined as the inability to perform a transfer safely and independently.

   

• Describe patient's Functional Mobility Skills & Deficits:

• Describe patient's Balance / Protective Reactions:

• Describe patient's Gross Motor Skills: (hopping, jumping up, forward/down stairs)

• Rate patient's Endurance:      Good Fair Poor

• Describe patient's Motor Planning abilities/deficits:

• Based on the findings of the standardized tests administered and the assessment of functional movements, please list the following:

  Assessment of Patient's Strengths:

  Assessment of Patient's Needs:

• Recommendation:

            It is recommended that receive direct physical therapy intervention for 1 time per week 2 times per week 3 times per week for 30 minutes each session 45 minutes each session 60 minutes each session Other, please describe below

• Recommendation Comments (if applicable):

• Long Term Goal / Objectives:

• Short Term Goals / Objectives:

• Name of Evaluating Therapist & Credentials:

          Juliet Caparas, PT Beth Dwiggins, PT Myra Hizola, PT                ______________________________________________________________________

                                                     (report must also be signed by therapist with full name & credentials)