Karuna Vihar EIC

Physiotherapy Assessment Form

Standing frame cum sitting chair – Assessment Form

Date: _____/_____/ 20__

Name of Child- ............................................. ........

Age/Gender- .........................................................

Weight (Kgs) …………………………………………...............

Height (inches) ……………………………………….................

Contact Details ………………………………………................

Assessor ………………………………………………..........

……………………………………………….........

Brief description of Neurological Impairment and associated secondary issues:

………………………………………………………………………………………………………………………................................

………………………………………………………………………………………………………………………...........................................

…………………………………………………………………………………………………………………......................................

……………........……………………………………………………………………………………………......................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

.........................................................................................................................................................

Measurement for Sitting Chair:Measurement for Sitting Chair:Measurement for Sitting Chair:Measurement for Sitting Chair:

Note: Assessment for sitting is done with child sitting on the low level stool with back unsupported.

Measurement for Standing Frame:Measurement for Standing Frame:Measurement for Standing Frame:Measurement for Standing Frame:

TYPE OF STANDING FRAME

Prone stander/Supine stander

With inclination/w/o inclination

Measurements with standard inch tape In Inches

Heel to Occiput

Heel to Acromian Process

Heel to Inferior angle of scapula

Heel to PSIS level

Heel to knee

Pelvic width

Standing Frame Measurement In Inches

1. Height of Standing Frame

2. Width of Standing Frame

Table/Desk Measurement

Length and width -

Depth of the circumference –

C size (Right to left midaxillary line with centre at xiphisternum) -

Longitudinal depth (Perpendicular line intersecting between midaxillary line and xiphisternum)-

Table Height:

Sitting chair (From buttocks to Olecranon process of elbow, when child is in sitting on a stool and elbow flexed

to 90 degree)-

Standing frame (from bottom of heel to Olecranon process of elbow with elbow flexed to 90 degree)-

Additional supports:- In Inches

Belts=

At the level of T2-T8(Chest belt)

At the level of Pelvis

Chest Harness

Velcro=

At the level of 2 ‘’ above Knee

2 At the level of 2 ‘’ below Knee

At the level of 2 ‘’ above medial malleolus

Mid foot level

AFO/Knee Gaiters/Arch Support/any other orthotic

Note: Assessment for standing frame has to be done in supine lying position.

Please describe any functional limitations not mentioned above, giving dimensions where appropriate:-

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

_________________________________________________________________________________

Signature and Name of PhysiotherapisSignature and Name of PhysiotherapisSignature and Name of PhysiotherapisSignature and Name of Physiotherapistttt