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