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Form PEMERIKSANAAN UMUM FT ANAK 300419

This Indonesian pediatric physiotherapy assessment form collects information about a child patient, including their medical history, reason for consultation, physical exam findings, physical therapy diagnosis, treatment plan, and evaluation. Physical assessments include range of motion, strength, posture, and functional abilities. Goals are set for short and long-term physical therapy.

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vano
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648 views4 pages

Form PEMERIKSANAAN UMUM FT ANAK 300419

This Indonesian pediatric physiotherapy assessment form collects information about a child patient, including their medical history, reason for consultation, physical exam findings, physical therapy diagnosis, treatment plan, and evaluation. Physical assessments include range of motion, strength, posture, and functional abilities. Goals are set for short and long-term physical therapy.

Uploaded by

vano
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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INDONESIAN PEDIATRIC PHYSIOTHERAPY ASSESSMENT FORM

 Initial Assesment  Re-Evaluation  Discharge

Physical Therapist :
Hospital/ Clinic :
Date :
Anamneses
Name: Date of birth:
No Medical Record :
Address: Occupation:

Reason for Consultation: Date of Assessment:

Medical/ Therapy History :

Other objective assessments:


- X-Ray
- CT.Scan
- MRI
- EMG
- EKG
- EEG
- Lab
Etc…

Mark the area of the body which has


problem.

Perhimpunan Fisioterapi Anak Indonesia (PFAI)


Indonesia Pediatric Physical Therapy Association (IPPTA)
General Assesment

Cara Datang:

Blood pressure:

Respiratory Rate:

Cardiac Rhythm:

Temperature :

Anthropometry:

Nutrition State:

Physical Therapy Intervention


Observation ( cara datang, atensi, emosi, Hypothesis:
motivasi, problem solving, postur, pola 1.
gerak, kemampuan, ketidak mampuan): 2.
3…..

Structure/ Function (postural tone and postural Activity: Participation:


pattern:

Perhimpunan Fisioterapi Anak Indonesia (PFAI)


Indonesia Pediatric Physical Therapy Association (IPPTA)
Personal factors: Environmental factors:

Main problem: Associate problems:

PT Diagnose : Goal Treatment (Short term goal and Long


term goal) :

Treatment Plan: Home Program:

Evaluation : Place :
Date :

Perhimpunan Fisioterapi Anak Indonesia (PFAI)


Indonesia Pediatric Physical Therapy Association (IPPTA)
Pt’s Signature :

Perhimpunan Fisioterapi Anak Indonesia (PFAI)


Indonesia Pediatric Physical Therapy Association (IPPTA)

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