Assesment performa for cerebral palsy

 Assesment form for cerebral palsy                                         

                                           ASSESSMENT  FORM

Name:____________________________________________________________

Gender___________________            Date of birth_________________________

Age: _________                            Months________ Days________Years_______

Hand Dominance____________________________________________________

Address:___________________________________________________________

Referred diagnosis:

Chief complaints:

HISTORY

Family history of abnormality(if yes, specify)________________________________

Pre natal history:

        i.            Health of the mother during pregnancy.

      ii.            Miscarriage/abortion

    iii.            Medication

    iv.            Serial number of pregnancy in this child

      v.            Death of siblings (if any)

    vi.            Hypertension/diabetes/anemia/other illness.

Perinatal history:

        i.            Type of delivery

      ii.            Short/prolonged labour

    iii.            Birth cry

    iv.            Prsence of congenital problems (if any)

      v.            Single/twins/triplets/others

    vi.            Birth history: premature  / Term / post mature

Post natal history:

        i.            Pneumonia

      ii.            High fever

    iii.            Jaundice

    iv.            Seizures

      v.            Medication

    vi.            Others

ON OBSERVATION

        i.            Posture

      ii.            Gait

    iii.            Deformity

    iv.            Assisstive devices

SENSORY EXAMINATION

REFLEXES

MOTOR EXAMINATION

BALANCE ASSESSMENT