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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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Scan doc0018
- 1. I' Multinational Life Insurance Company - cSeguro te !ResponcCe- GAil Jj)fE~Cm~TI(jlN SSN: ~~-93- Vy? ? 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) D a t e I elephone/ Fax Avenida Munoz Rivera 510, San Juan, Puerto Rico 00918 e PO Box 366107 San Juan, PR 00936-6107 " Tel. 787-758-8080