HULL & EAST YORKSHIRE HOSPITALS NHS TRUST Page 1 of 8
PHYSIOTHERAPY DEPARTMENT
AMPUTEE REHABILITATION SERVICE: ASSESSMENT FORM
PREFERRED NAME:
NAME: .....
CONSULTANT: .
DOB: UNIT NO: .
GP: ...
NHS NUMBER: ..
ADDRESS: .
ADDRESS: ..
...
TEL NO: ...
TEL NO: ..
DATE OF ASSESSMENT: ..
CONTACT DETAILS NEXT OF KIN:
OTHERS:
AMPUTATION DETAILS:
Right Hospital Date of Left Hospital Date of
Ward Surgery Ward Surgery
Transfemoral Transfemoral
Transtibial Transtibial
HISTORY OF PRESENT CONDITION
PREVIOUS MEDICAL HISTORY:
CVA CARDIAC DIABETES
Respiratory conditions
Known Allergies Latex
Other
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
Physiotherapy Service, Amputee Rehabilitation Service Assessment form 2009
Page 2 of 8
NAME: ...
DOB: ..
UNIT NO: ..
NHS NO: ...
DRUGS HISTORY: Has medication review taken place in last 6 months: Yes / No
*Falls risk: Poly pharmacy 4 or medicines
CONTINENCE
Bladder: frequency urgency nocturnal frequency (*Falls risk)
Bowels:
SENSORY
SIGHT: Difficulty seeing across the room Difficulty reading
Wears glasses: Bifocals/Varifocals (*Falls risk)
Sight test last 12 months Yes / No
Hearing: use of hearing aid(s)
Alcohol: *Falls risk Smoking habit:
Emotional state: Social / Leisure activities:
Car driver: Driving after Amputation, 6th edition Oct 2006 Booklet given
RDAC Empowering people Leaflet given
Occupation:
SOCIAL HISTORY
House Own
Part of a House Rented
Bungalow Council
Flat With Spouse
Sheltered With family
Other Alone
ACCESS (indicate number of steps/ramp/rails etc): *Falls risk:: has environment been assessed
Front Rear/Side
Stairs Stair Lift Through floor lift
Outdoor steps/slope
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
Physiotherapy Service, Amputee Rehabilitation Service Assessment form 2009
Page 3 of 8
NAME: ...
DOB: ..
UNIT NO: ..
NHS NO: ...
AMENITIES
Bathroom / Shower Toilet
AIDS CURRENTLY PROVIDED
Bath/shower Toilet
Other
PRE-AMPUTATION FUNCTIONAL INDEPENDENCE
Dressing Toilet Bath
Shopping Cooking
PRE-AMPUTATION MOBILITY / DISTANCE See Locomotor Index
Outdoors:
Limited by: Pain (R) Leg (L) Leg Other
Aids used:
Wheelchair Motorised Scooter
Indoors:
Limited by: Pain (R) Leg (L) Leg Other
Aids used:
Wheelchair: self propelled Electric: indoor outdoor
CURRENT FUNCTIONAL MOBILITY AND TRANSFERS
Wheelchair mobility
Bed mobility
Dressing
Gait (if applicable)
Transfers
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
Physiotherapy Service, Amputee Rehabilitation Service Assessment form 2009
Page 4 of 8
NAME: ...
DOB: ..
UNIT NO: ..
NHS NO: ...
PHYSICAL ASSESSMENT
Record on body map sites of pain, altered sensation, pressure areas,
Right Left Right
RESIDUUM:
Wound Pain
Oedema
Phantom sensations
*Falls risk
ROM/POWER
LEGS: Affected Unaffected
HIP
KNEE
ANKLE
SKIN CONDITION *1
SENSATION / PROPRIOCEPTION
PRESSURE AREAS
*1 SKIN include: temp, colour, hair growth, nail condition, oedema, presence of lesions
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
Physiotherapy Service, Amputee Rehabilitation Service Assessment form 2009
Page 5 of 8
NAME: ...
DOB: ..
UNIT NO: ..
NHS NO: ...
ROM/POWER
ARMS: Left Right
SHOULDER
ELBOW
WRIST
HAND / GRIP
SKIN CONDITION *1
SENSATION / PROPRIOCEPTION
*1 SKIN include: temp, colour, hair growth, nail condition, oedema, presence of lesions
TRUNK: Posture: in sitting in standing with prosthesis
Balance: in sitting in standing with/without prosthesis
*Falls risk:
BACK: Range of Movement Pain
NECK: Range of Movement Pain
Dizziness *Falls risk
PULSES
RIGHT LEFT
Femoral Femoral
Popliteal Popliteal
Posterior Tibial Posterior Tibial
Dorsalis Pedis Dorsalis Pedis
CARDIO RESPIRATORY STATUS
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
Physiotherapy Service, Amputee Rehabilitation Service Assessment form 2009
Page 6 of 8
NAME: ...
DOB: ..
UNIT NO: ..
NHS NO: ...
FALLS HISTORY Number of falls in last 6 months
Any injuries / fractures as a result of falls A & E attendance Hospital admission
History of previous falls Time: am / pm
Location: Indoor / Outdoor
Activity at time of fall
Were you able to get up from floor: Yes / No
Were you able to seek help? Yes / No
History of latest falls Time: am / pm
Location: Indoor / Outdoor
Activity at time of fall
Were you able to get up from floor: Yes / No
Were you able to seek help? Yes / No
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
FUNCTIONAL STATUS AT DISCHARGE FROM HOSPITAL
Wheelchair mobility
Manipulation of wheelchair components:
Foot rest Support board Arm rests Brakes
Transfer from wheelchair to / from:
Bed Toilet / Commode Arm chair Car
Bed mobility:
Rolling Sitting up Bridging
Hop with Aid (if appropriate)
Step Stairs
Get up off floor Other
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
Physiotherapy Service, Amputee Rehabilitation Service Assessment form 2009
Page 7 of 8
NAME: ...
DOB: ..
UNIT NO: ..
NHS NO: ...
ARTIFICIAL LIMB
Type: Prosthetist:
Date received : Contractor:
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
FUNCTIONAL STATUS AT DISCHARGE FROM OUT-PATIENT PHYSIOTHERAPY SERVICE
Progress towards achievement of patients own long term expectations / goals (see separate
document)
Don / Doff Prosthesis Dress
Mobility Indoors Mobility Outdoors
Toilet Bath
Step Stairs
Slope Rough ground
In / out car Public transport
Get up off floor with prosthesis without prosthesis
Other
DATE OF HOME VISIT (if appropriate):
DATE OF DISCHARGE FROM HOSPITAL:
DATE OF DISCHARGE FROM OUTPATIENT PHYSIOTHERAPY SERVICE:
DATE OF DISCHARGE SUMMARY SENT TO GP/CONSULTANT:
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
Physiotherapy Service, Amputee Rehabilitation Service Assessment form 2009
Page 8 of 8
NAME: ...
DOB: ..
UNIT NO: ..
NHS NO: ...
LOCOMOTOR INDEX MIMIMUM SCORE = 14 MAXIMUM SCORE = 56
6 months pre- Initial
amputation assessment
post delivery
DATE:
1. Get up from a chair
2. Pick up an object from the floor when standing
3. Get up from the floor
4. Walk indoors
5. Walk outside on even ground
6. Walk outside on uneven ground (eg grass,
gravel, slope)
7. Walk outside in bad weather (eg rain, snow)
8. Go up the stairs with a handrail
9. Go down the stairs with a handrail
10. Step up a kerb
11. Step down a kerb
12. Go up a few steps without a handrail
13. Go down a few steps without a handrail
14. Walk while carrying an object
TOTAL SCORE:
PRINT NAME & SIGNATURE OF ASSESSOR:
DESIGNATION OF ASSESSOR:
KEY:
1 = No 2 = Yes, if someone helps 3 = Yes, if someone is near 4 = Yes, alone
1st Early Last Early 1st Prosthesis 2 weeks post Discharge
Walking Aid Walking Aid delivery
DATE:
Timed 10 metre walk
Timed L Get up and Go
PRINT NAME & SIGNATURE OF
ASSESSOR
DESIGNATION OF ASSESSOR
Information Obtained From: Date:
Signature: Print Name: ............ Physiotherapist
Physiotherapy Service, Amputee Rehabilitation Service Assessment form 2009
