IBAN: IT36M0708677020000000008016 - BIC/SWIFT:
ICRAITRRU60 - VALERIO DI STEFANO or
EXAMINATION 39
SAMPLE RECORD SHEET FOR PHYSICAL EXAM
Child’s name___________________________________
File number________________
RECORD
SHEET
2
Mark on the drawings where
you find the problems. Use
lines and circles together with
abbreviations shown on this
page. For example:
Where necessary, make new
drawings on another sheet.
Parts of body affected
L or R ________________ other ________________
(indicate)
OW: Pain OW-J pain in joints
OW-M pain in muscles
0 none
+little
++a lot
+++so much that she
does not move it
CTR: contractures
� tight muscles do not
yield with pressure
SP: spasticity
� *tight muscles
yield slowly with
pressure
R L
R L
R L
Strength or weakness of muscles: Use this code
NORMAL lifts and holds
5 against strong
POOR moves some but
2 cannot lift own
resistance
weight
GOOD
4
moves against
some resistance
TRACE barely moves
1
FAIR
3
lifts own weight
but no more
ZERO no sign of
0 movement
T: abilit y to feel, touch, pain, etc.
other
Deep tendon relexes:
Problems with
____ *Eyes or sight.
What:____________
______________________
____*Ears or hearing.
What:____________
______________________
hunchback
(kyphosis)
Spine
side ways
curve
(scoliosis)
sway back
(lordosis)
hard
bump
(TB?)
Right knee
Left knee
O t h e r _______
HT: hips tilt
DL: dislocations:
hip
RL
from old
birth
new
knee
curve fixed_ ___ curve can straighten_ __
(See p. 161.)
R leg shor ter____
L leg shor ter___ by________ cm
elbow
other___________
* Spina bifida
soft sac
*large head
(hydrocephalus)
back already operated ____ date______
head already operated_ ___ date_ _____
extent of paralysis___________________
______________________________________
extent of feeling lost_ _______________
______________________________________
*Spinal cord injury
what level_____________________
Bowel
control
Bladder
control
Good
Poor
None
Other problems
____ *pressure sores
____ *unusual
movements
____ *tremors
____ *seizures
____ *poor balance
____ *developmental
delay
IMPORTANT: This form does not cover all the
tests and information you will want to record when
examining a child. Put other information on the back
of this sheet. Or use separate sheets or forms.
*If you check any problem area marked with a star (*), a
more complete check of the nervous system is needed.
You can use the RECORD SHEETS 3, 4, and 6.
disabled village children
Static
Wikipedia 2008 (no
images)
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got
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ksh
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kv
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kw
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la
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lad
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lb
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lbe
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lg
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li
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lij
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lmo
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lo
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lt
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lv
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map_bms
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mdf
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nl
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nrm
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nv
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pag
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pam
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pap
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pdc
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quality
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rmy
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rn
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sa
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simple
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uk
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vec
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vi
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vls
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vo
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war
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wo
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wuu
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xal
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xh
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yi
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yo
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za
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zea
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zh
-
zh_classical
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zh_min_nan
-
zh_yue
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zu
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Static
Wikipedia 2007 (no
images)
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bg
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bh
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bm
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bpy
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br
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bug
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bxr
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ca
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cbk_zam
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cdo
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ceb
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ch
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chr
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chy
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crh
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cv
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fr
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frp
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fur
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ga
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gan
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gd
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gl
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glk
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got
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hak
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hi
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ka
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kaa
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kab
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ki
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kj
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kk
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kl
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km
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kn
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ko
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kr
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ks
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ksh
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ku
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kv
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kw
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ky
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la
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lad
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lb
-
lbe
-
lg
-
li
-
lij
-
lmo
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ln
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lo
-
lt
-
lv
-
map_bms
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mdf
-
mg
-
mh
-
mi
-
mk
-
ml
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mn
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mo
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mr
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mt
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mus
-
my
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myv
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mzn
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na
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nah
-
nap
-
nds
-
nds_nl
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ne
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new
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ng
-
nl
-
nn
-
no
-
nov
-
nrm
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nv
-
ny
-
oc
-
om
-
or
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os
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pa
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pag
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pam
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pap
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pdc
-
pi
-
pih
-
pl
-
pms
-
ps
-
pt
-
qu
-
quality
-
rm
-
rmy
-
rn
-
ro
-
roa_rup
-
roa_tara
-
ru
-
rw
-
sa
-
sah
-
sc
-
scn
-
sco
-
sd
-
se
-
sg
-
sh
-
si
-
simple
-
sk
-
sl
-
sm
-
sn
-
so
-
sr
-
srn
-
ss
-
st
-
stq
-
su
-
sv
-
sw
-
szl
-
ta
-
te
-
tet
-
tg
-
th
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ti
-
tk
-
tl
-
tlh
-
tn
-
to
-
tpi
-
tr
-
ts
-
tt
-
tum
-
tw
-
ty
-
udm
-
ug
-
uk
-
ur
-
uz
-
ve
-
vec
-
vi
-
vls
-
vo
-
wa
-
war
-
wo
-
wuu
-
xal
-
xh
-
yi
-
yo
-
za
-
zea
-
zh
-
zh_classical
-
zh_min_nan
-
zh_yue
-
zu
-
Static
Wikipedia 2006 (no
images)
aa
-
ab
-
af
-
ak
-
als
-
am
-
an
-
ang
-
ar
-
arc
-
as
-
ast
-
av
-
ay
-
az
-
ba
-
bar
-
bat_smg
-
bcl
-
be
-
be_x_old
-
bg
-
bh
-
bi
-
bm
-
bn
-
bo
-
bpy
-
br
-
bs
-
bug
-
bxr
-
ca
-
cbk_zam
-
cdo
-
ce
-
ceb
-
ch
-
cho
-
chr
-
chy
-
co
-
cr
-
crh
-
cs
-
csb
-
cu
-
cv
-
cy
-
da
-
de
-
diq
-
dsb
-
dv
-
dz
-
ee
-
el
-
eml
-
eo
-
es
-
et
-
eu
-
ext
-
fa
-
ff
-
fi
-
fiu_vro
-
fj
-
fo
-
fr
-
frp
-
fur
-
fy
-
ga
-
gan
-
gd
-
gl
-
glk
-
gn
-
got
-
gu
-
gv
-
ha
-
hak
-
haw
-
he
-
hi
-
hif
-
ho
-
hr
-
hsb
-
ht
-
hu
-
hy
-
hz
-
ia
-
id
-
ie
-
ig
-
ii
-
ik
-
ilo
-
io
-
is
-
it
-
iu
-
ja
-
jbo
-
jv
-
ka
-
kaa
-
kab
-
kg
-
ki
-
kj
-
kk
-
kl
-
km
-
kn
-
ko
-
kr
-
ks
-
ksh
-
ku
-
kv
-
kw
-
ky
-
la
-
lad
-
lb
-
lbe
-
lg
-
li
-
lij
-
lmo
-
ln
-
lo
-
lt
-
lv
-
map_bms
-
mdf
-
mg
-
mh
-
mi
-
mk
-
ml
-
mn
-
mo
-
mr
-
mt
-
mus
-
my
-
myv
-
mzn
-
na
-
nah
-
nap
-
nds
-
nds_nl
-
ne
-
new
-
ng
-
nl
-
nn
-
no
-
nov
-
nrm
-
nv
-
ny
-
oc
-
om
-
or
-
os
-
pa
-
pag
-
pam
-
pap
-
pdc
-
pi
-
pih
-
pl
-
pms
-
ps
-
pt
-
qu
-
quality
-
rm
-
rmy
-
rn
-
ro
-
roa_rup
-
roa_tara
-
ru
-
rw
-
sa
-
sah
-
sc
-
scn
-
sco
-
sd
-
se
-
sg
-
sh
-
si
-
simple
-
sk
-
sl
-
sm
-
sn
-
so
-
sr
-
srn
-
ss
-
st
-
stq
-
su
-
sv
-
sw
-
szl
-
ta
-
te
-
tet
-
tg
-
th
-
ti
-
tk
-
tl
-
tlh
-
tn
-
to
-
tpi
-
tr
-
ts
-
tt
-
tum
-
tw
-
ty
-
udm
-
ug
-
uk
-
ur
-
uz
-
ve
-
vec
-
vi
-
vls
-
vo
-
wa
-
war
-
wo
-
wuu
-
xal
-
xh
-
yi
-
yo
-
za
-
zea
-
zh
-
zh_classical
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zh_min_nan
-
zh_yue
-
zu
-
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