Infant Spinal Cord Termination Assessment Form
Assessment tool for evaluating infant spinal cord termination condition
Evaluator Name
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Infant Age (months)
*
Gender
*
Male
Female
Other/Undisclosed
Clinical Presentation
*
Lower limb weakness
Spasticity
Hypotonia
Bladder dysfunction
Other
Neurological Examination Findings
*
Rows
Normal
Abnormal
Not Assessed
Reflexes
1
2
3
Muscle Tone
4
5
6
Motor Function
7
8
9
Sensory Function
10
11
12
Imaging Findings (MRI/Ultrasound)
*
Abrupt cord termination
Tapered cord
Associated vertebral anomalies
Other
Severity of Neurological Impairment
*
No impairment
1
2
3
4
Severe impairment
5
1 is No impairment, 5 is Severe impairment
Likelihood of Spinal Cord Termination Condition
*
Unlikely
Possible
Probable
Definite
Additional Comments or Observations
Submit Assessment
Should be Empty: