Institute of Physical Medicine And Rehabilitation

Dow university of health sciences

Geriatric PHYSICAL THERAPY ASSESSMENT
Date: ______________
Name:_____________________________________________
Height _______ Weight ______ Age _______ Blood Pressure: ___________
Education:
Highest grade completed
___ Some college/ technical school
___ College school / advance degree
___ Graduate School/Advance Degree
Occupation:______________________________________ Religion:______________________________________
Address/ contact no:____________________________________________________________________________________________

With whom do you live?

____Alone ____Spouse only
____Spouse and others ____Child(not spouse)
____Other relative(s) (not spouse ____Personal care attendant or children)

Does your home have: Do you use:

____Stairs, no railing ____Cane
____Stairs, w/railing ____Walker or rollator
____Ramps ____Manual Wheelchair
____Elevator
____Uneven Terrain Other________________
____Other Obstacles: _______________________

Family History
Heart disease: ______________________________________Hypertension: _____________________________________
Stroke:____________________________________________Diabetes:__________________________________________
Cancer:____________________________________________Other: ___________________________________________

Present complain(s):________________________________________________________________________________________________________
HOPC:____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Aggravating factors
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Relieving factors:
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
PMH:_____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________

Which of these words describe your pain? sharp dull tingling aching burning numb constant variable radiating

Therapist Initials: ___________________________

 Institute of Physical Medicine And Rehabilitation
Dow university of health sciences
Geriatric PHYSICAL THERAPY ASSESSMENT
Date: ______________
Name:_____________________________________________
BODY CHART

VAS

MUSCULOSKELETAL ASSESSMENT
Observation_________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
AROM_____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________P
ROM______________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Palpation___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Special tests ______________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Therapist Initials: ___________________________

 Institute of Physical Medicine And Rehabilitation
Dow university of health sciences
Geriatric PHYSICAL THERAPY ASSESSMENT
Date: ______________
Name:_____________________________________________

NEUROLOGICAL ASSESSMENT:
Conscious level

Quality of movement_________________________________________________________________________________________
Apparent neglect____________________________________________________________________________________________
Gait_____________________________________________________________________________________________________

FUNCTIONAL MOVEMENT TESTED:

Level of independence:
6- independent, 5- requires supervision, 4- require verbal cues, 3- requires minimal physical assistance of 1
2- requires moderate physical assistance of 1, 1- requires physical assistance of 2, 0- unable to perform with maximal assistance
Supine to side lying: side lying to sitting over edge of bed:

SITTING BALANCE:
Static dynamic

STANDING STATIC BALANCE

feet apart feet together
stride stance single stance

STANDING DYNAMIC BALANCE (during movements,rotations, picking up objects):

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
FUNCTIONAL BALANCE TEST
func. reach test:_____________________________________________________________________________________________
get up and go test:___________________________________________________________________________________________
Therapist Initials: ___________________________
 Institute of Physical Medicine And Rehabilitation
Dow university of health sciences
Geriatric PHYSICAL THERAPY ASSESSMENT
Date: ______________
Name:_____________________________________________

CARDIORESPIRATORY FITNESS EXERCISE CAPACITY TEST:

6 minute walk test:___________________________________________________________________________________________
RPE:________________________________________
HR:_________________________________________

MEASUREMENT OF PERCEPTION AND COGNITION:

Mini mental state examination (MMSE):_______________ Geriatric depression scale (GDS):__________________

PROBLEM LIST:

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
________________________________________________________________________________

GOALS:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
__________________________________________________________________________________________

TREATMENT:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________

Therapist Initials: ___________________________