This document contains a medical assessment of a patient's gait and mobility. It includes questions about the patient's use of assistive devices, including canes, orthopedic shoes, and prosthetics. The physician examines the patient's gait both with and without assistive devices, noting any abnormalities, limb weakness, or other issues that impact mobility. Medical findings are recorded, such as muscle atrophy, spasticity, or involuntary movements. The physician determines if prescriptions for assistive devices or prosthetics are needed.
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1. ts the g~it: DNorm~1 DAnt~lgic? DProtecting one I~g: ORt
Olt leg
OWith el rigid
spine?
2. Does the patient DUmp? F~voril1g: DIRt OLt leg Delmg a leg due to
weakness? 0 Rt Ou leg
Djust keep the leg rigid but bears weight IOn it? commems; ____ _
3. Strength Ell lower eY.tremiti~: Right:, _____________Left
. ls mere atrophy present? DYes ONo. Location and.
measurements:
--------------------~--------------------------------
4. Are any of these findings present which alter gait? DAtaxia
Dlack of balance 0 lack of coordination: ORt DLt leg
Comments: _________________________________________________--:..._--------- -
5. Does the patient use: DCane: DRt OLt hand 0 Orthopedic shoes 0 Shoe lift DCrutches
DWheelcl1air DAFO (asslstive foot orthotic): DRt Dlt foot DProsthetic
limbs ORt Du leg
Comments:. _________________-:- ___________________________________ _
6. Did you examine patient's gait without asslsnve device? DYes ONe ON/A
7. Did you examine patient's gait Vl,tith prosthesis in place? DYes ONo ON/A
8. Did a physician prescribe assistlve device or prosthesis? DNo Dyes. If so, please indicate
physician's name:
---
9. Describ~ gait while using ormopedic shoes or lift: DNormal OAbnormal. Explain: _
10. Describe gait usirlg prosthetic limb. UNormalDAb normal. Explain: _
9. Any problem at stump area? ONe Dyes. Explain:, ___________________________________________
-..,.. _
10. Is the cane considered necessary all the time and in all types of terrain? DNo Dyes. Why? ________
_
11. Does the patient use the walls or require someone's assistence for support? DNa DYes. if
support is necessaN
does it mean that he/she needs some kind Qf asslstlve device? ONo DYes. Explain: < ,
DSpasticity
Dll1voJuntary movements
DUnstable joint DRigid tone DFlaccid tone.
2. Offic-e dayslhou!"s: Mon _____________Tue. _____________Vfed. ____________Thu ___________Fri. _________
Sat:
._----
Physician's
Signature
Physician's Name (Please
print)
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Avenida Munoz Rivera 510, San Juan, Puerto Rico 00918 e PO Box 366107 San Juan, PR 00936-6107 " Tel.
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