Focal Spasticity Multidisciplinary Proforma

200 201 202 203 204 205 206 Confidential Patient Information

Patient Name (or attach ID Label)

Hospital/NHS Number

Date of Birth

Address

Email

Home Telephone Number

Work Telephone Number

Mobile Telephone Number

ALL STAFF SIGNING FOR CARE MUST RECORD BELOW DETAILS OF THEIR FULL NAME, POSITION AND SAMPLE SIGNATURE

POSITION

FULL NAME

SIGNATURE

INITIAL

EXT

Date of Initial Assessment

Date of Follow-up Appointment

1.

2.

3.

4.

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CNS

Clinical Nurse Specialist

Add

Adductor

GP

General Practitioner

Flex

Flexion

SpR

Specialist Registrar

Ext

Extension

PT

Physiotherapist

UL

Upper limb

OT

Occupational Therapy

LL

Lower Limb

Pt

Patient

R

Right

ITB

Intrathecal Baclofen

L

Left

BT

Botulinum Toxin

DIP

Distal Interphalangeal Joint

IP

Intrathecal Phenol

PIP

Proximal Interphalangeal Joint

ISC

Intermittent Self Catheterisation

MCP

Metacarpophalangeal Joint

LMWH

Low molecular weight heparin

MTP

Metatarsophalangeal Joint

INR

International Normalised Ratio

EMG

Electromyography

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Muscle Abbreviations

Acceptable abbreviations used in this proforma

Upper Limb

Delt

Deltoid

ECR

Extensor carpi radialis

Lat d

Latissimus dorsi

ECU

Extensor carpi ulnaris

Pec Maj

Pectoralis major

E dig

Extensor digitorum

Pec Min

Pectoralis minor

E dig min

Extensor digiti minimi

Biceps

Biceps brachii

EPL

Extensor pollicis longus

Brach

Brachialis

EPB

Extensor pollicis brevis

BR

Brachioradialis

Add poll

Adductor pollicis

FCR

Flexor carpi radialis

Abd poll

Abductor pollicis brevis

FCU

Flexor carpi ulnaris

Lumb

Lumbricals

FDS

Flexor digitorum superficialis

Pron ter

Pronatus teres

FDP

Flexor digitorum profundus

Pron quad

Pronator quadratus

FPL

Flexor pollicis longus

Supin

Supinator

FPB

Flexor pollicis brevis

Lower Limb

Add mag

Adductor magnus

Tib ant

Tibialis anterior

Add long

Adductor longus

Tib post

Tibialis posterior

Add brev

Adductor brevis

EDL

Extensor digitorum longus

Semi-m

Semi-membranous

EHL

Extensor hallicus longus

Semi-t

Semi-tendinous

Gastroc

Gastrocnemius

Biceps f

Biceps femoris

Soleus

Soleus

Psoas

Psoas Major

FHL

Flexor hallicus longus

Iliac

Iliacus

FHB

Flexor hallicus brevis

FDB

Flexor digitorum brevis

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