| 1. Visual fields: Shade in any areas of deficit. |  |
2. Visual acuity: _________________ OU
Was the patient wearing corrective lenses? If yes, please specify: ______________________________________
3. Rapid pace walk: ____________ seconds
Was this performed with a walker or cane? If yes, please specify: ______________________________________
4. Range of motion: Specify ‘Within Normal Limits’ or ‘Not WNL.’ If not WNL, describe.
Neck rotation Finger curl Shoulder and elbow flexion Ankle plantar flexion Ankle dorsiflexion Notes:
5. Motor strength: Provide a score on a scale of 0-5.
Shoulder adduction Shoulder abduction Shoulder flexion Wrist flexion Wrist extension Hand grip Hip flexion Hip extension Ankle dorsiflexion Ankle plantar flexion
6. Trail-Making Test, Part B: ____________ seconds
7. Clock drawing test: Please check ‘yes’ or ‘no’ to the following criteria.
All 12 hours are placed in correct numeric order, starting with 12 at the top Only the numbers 1-12 are included (no duplicates, omissions, or foreign marks) The numbers are drawn inside the clock circle The numbers are spaced equally or nearly equally from each other The numbers are spaced equally or nearly equally from the edge of the circle One clock hand correctly points to two o’clock The other hand correctly points to eleven o’clock There are only two clock hands