Inner banner
Internal mini form
Contact Us Today
A diagnosis of Cerebral Palsy will come only after several evaluations, observations and tests are performed. The Cerebral Palsy Diagnosis Checklist allows parents to document test results, appointment outcomes, and formal diagnosis on one easy-to-use form. It is likely parents will share these details with school officials, other health care providers, therapists and caregivers in the months and years ahead. The checklist can be easily stored in a child’s home medical records for easy retrieval.
About a Cerebral Palsy diagnosis
With Cerebral Palsy, every child’s condition is unique. Some may have a mild form, others severe. The impairment may involve one limb, two, three or all four. The child may have paresis or paralysis. The cause of impairment is due to one of four classifications of brain damage, which should be accurately relayed to those charged with a child’s care.
Obtaining a Cerebral Palsy diagnosis is often a lengthy process. Usually, a child’s development is observed over time. The child’s primary health care provider, often a pediatrician, looks for signs of impairment during well-baby checkups. A parent notices symptoms that may indicate concern, such as delayed developmental milestones. Tests may be ordered and medical specialists consulted.
During this process, the child’s parent or legal guardian is provided with observations, test results and diagnosis. A Cerebral Palsy diagnosis can be overwhelming as a parent begins to realize his or her child has a physical impairment that cannot be cured, but can be managed. Often, parents retain only a portion of information initially presented by doctors and other medical practitioners. Questions arise later, yet many parents do not know what questions will provide answers and help fully define the child’s condition.
As the child grows, parents will meet with school administrators, physical therapists, adaptive equipment specialists, home care providers, and more. In initial consults, the parent will be asked the cause, type, and form of Cerebral Palsy their child has. Some medical specialists find it helpful to know the extent, location, and severity of the child’s impairment.
The industry may use various common medical terms to define various aspects of the child’s impairment., Although health care providers will likely confirm diagnosis with the child’s primary care physician before formally treating the child, a parent may nonetheless benefit from a sheet cataloging this information for such interactions.
The Diagnosis Checklist is designed by MyChild™ to provide a parent with better understanding and an easy-to-use checklist to document a child’s condition as provided by health care providers. Over the course of the child’s lifetime, it is likely parent will need to provide this information to many individuals caring for the child. The information can be easily stored in the child’s home medical records. Consult with a physician to check off all conditions that apply.
Basic Information
____________________ Child’s Name
____________________ Mother’s Name
____________________ Father’s Name
____________________ Primary Care Physician
____________________ Birth Date
____________________ Birth Weight
____________________ Birth Height
____________________ Week’s Gestation
____________________ APGAR Score
____________________ Blood Type
Cause of Cerebral Palsy Checklist
▢ Hypoxic-Ischemic Encephalopathy, or HIE – Lack of oxygen to the brain or asphyxia
▢ Intracranial Hemorrhage, or IVH – Brain Hemorrhage
▢ Periventricular Leukomalacia, or PVL – Damage to white matter tissue in the brain
▢ Cerebral Dysgenesis – Brain malformation, abnormal brain development
▢ Other ____________________
▢ None
When Brain Damage Occurred Checklist
▢ Acquired Cerebral Palsy – The child did not have Cerebral Palsy at the time of birth. Cerebral Palsy was acquired after birth, but before brain was fully developed.
▢ Congenital Cerebral Palsy – The child was born with the condition. Brain damage occurred during pregnancy, at birth, or immediately after birth.
▢ Genetic Predisposition to Cerebral Palsy – Cerebral Palsy is not considered to be hereditary, but hereditary conditions predisposed the child to Cerebral Palsy.
▢ No Cerebral Palsy – The brain damage occured after the brain has fully developed causing impairment similar to Cerebral Palsy, but is clinically identified by the actual cause.
▢ Not Determined – Timing of brain damage has not yet been determined.
Severity Level Checklist
▢ Mild – Cerebral Palsy means a child can move without assistance. Their daily activities are not limited.
▢ Moderate – Moderate Cerebral Palsy means a child will need braces, medications, and adaptive technology to accomplish daily activities.
▢ Severe – Severe Cerebral Palsy means a child will require a wheelchair and will have significant challenges in accomplishing daily activities.
▢ Other ____________________
▢ None
Topographical Distribution Checklist
Extent:
▢ Paresis means weakened
▢ Plegia means paralyzed
Prefix:
▢ Monoplegia/Monoparesis means that only one limb is affected. It’s thought that this may be a form of hemiplegia/hemiparesis where one limb is significantly impaired.
▢ Diplegia/Diparesis usually indicates that the legs are affected more than the arms. Primarily lower body involvement.
▢ Hemiplegia/Hemiparesis indicates that the arm and leg on one side of the body is affected.
▢ Paraplegia/Paraparesis means the lower half of the body, including both legs, are affected.
▢ Triplegia/Triparesis indicates that three limbs are affected. This could be both arms and a leg, or both legs and an arm. Or, it could refer to one upper and one lower extremity and the face.
▢ Double Hemiplegia/Double Hemiparesis indicate that all four limbs are involved, but one side of the body is more affected than the other.
▢ Tetraplegia/Tetraparesis indicates that all four limbs are involved, but three limbs are more affected than the fourth.
▢ Quadriplegia/Quadriparesis means that all four limbs are involved.
▢ Pentaplegia/Pentaparesis means that all four limbs are involved, with neck and head paralysis often accompanied by eating and breathing complications.
▢ Other ____________________
▢ None
Motor Function Checklist
Muscle Tone:
▢ Hypertonia — increased muscle tone often resulting in very stiff limbs. Hypertonia is associated with spastic Cerebral Palsy
▢ Hypotonia — decreased muscle tone often resulting in loose, floppy limbs. Hypotonia is associated with non-spastic Cerebral Palsy
Spasticity:
▢ Spastic (Pyramidal) – Spasticity means increased muscle tone. Muscles continually contract making limbs stiff, rigid, and resistant to flexing or relaxing. Reflexes can be exaggerated and movements jerky and awkward.
▢ Non-Spastic (Extrapyramidal) – Non-spastic Cerebral Palsy is decreased and/or fluctuating muscle tone. There are multiple forms, each characterized by particular impairments. One of the main characteristics of non-spastic Cerebral Palsy is involuntary movement. Movement can be slow or fast, often repetitive, and sometimes rhythmic.
▢ Mixed – It is common for a case to involve both spastic and non-spastic Cerebral Palsy. When a child’s impairments fall into both categories, it is considered mixed Cerebral Palsy. The most common form of mixed Cerebral Palsy sees some limbs affected by spasticity and others by athetosis.
Non-Spastic Sub-Categories:
▢ Ataxic – Ataxic Cerebral Palsy affects coordinated movements. Balance and posture are involved. Walking gait is often very wide, and possibly irregular. Control of eye movements and depth perception can be impaired. Often fine motor skills requiring coordination of the eyes and hands, such as writing, are made difficult.
▢ Dyskinetic – Dyskinetic Cerebral Palsy is separated further into two different groups; athetoid and dystonic. Athetoid Cerebral Palsy includes the cases with involuntary movement, especially in the arms, legs, and hands. Dystonic Cerebral Palsy encompasses the cases that affect the trunk muscles more than the limbs, and results in fixed, twisted posture.
▢ Athetosis — slow, writhing movements that are often repetitive, sinuous, and rhythmic.
▢ Chorea — irregular movements that are not repetitive or rhythmic, and tend to be more jerky and shaky.
▢ Choreoathetoid — a combination of chorea and athetosis, where the movements are irregular, but twisting and curving.
▢ Dystonia — involuntary movements accompanied by an abnormal, sustained posture.
▢ Ataxia — does not have to do with involuntary movements, but instead indicates impaired balance and coordination.
▢ Other ____________________
▢ None
Gross Motor Function Classification System Checklist
▢ GMFCS Level I. Walks without limitations.
▢ GMFCS Level II. Walks with limitations. Has limitations walking long distances and balancing. Not as able as Level I to run or jump. May require use of mobility devices when first learning to walk, usually prior to age 4. May rely on wheeled mobility equipment when outside of home for traveling long distances.
▢ GMFCS Level III. Walks with adaptive equipment assistance. Requires hand-held mobility assistance to walk indoors, while utilizing wheeled mobility outdoors, in the community and at school. Can sit on own or with limited external support. Has some independence in standing transfers.
▢ GMFCS Level IV. Self-mobility with use of powered mobility assistance. Usually supported when sitting. Limited self-mobility. Likely to be transported in manual wheelchair or powered mobility.
▢ GMFCS Level V. Severe head and trunk control limitations. Requires extensive use of assisted technology and physical assistance. Transported in a manual wheelchair, unless self-mobility can be achieved by child learning to operate a powered wheelchair.
▢ Other ____________________
▢ None
Orthopedic Impairment Assessment Checklist
▢ Muscle Tone
▢ Movement Coordination and Control
▢ Reflexes
▢ Posture
▢ Balance
▢ Gross Motor Function
▢ Fine Motor Function
▢ Oral Motor Function
▢ Other ____________________
▢ None
Associative Conditions and Co-Mitigating Factors Checklist
▢ Behavior
▢ Cognition
▢ Communication
▢ Developmental Delay
▢ Digestive Health
▢ Dysphagia
▢ Hearing
▢ Mobility
▢ Neurologic Health
▢ Nutrition Health
▢ Oral Health
▢ Orthopedic Health
▢ Respiratory Health
▢ Seizure Control
▢ Sensory
▢ Skin Health
▢ Socialization
▢ Vision
▢ Other ____________________
▢ None
