Monday, September 29, 2008

Physical Therapy Assessment Chart

Physical Therapy Assessment Chart

 

Patient ID                                 :

Name                                       :

Age & Sex                               :

Address                                   :

Occupation                              :

Life Style                                 :           Non Smoker:               Smoke             /Day

                                                            No Alcoholic:              Alcohol                        /Day

                                                            No Exercise:                Exercise           /Day

Past medical history                 :

 

 

Present medical history                        :

 

 

 

Vital parameters                       :

-          Temperature          :

-          Pulse                      :

-          Blood pressure       :

-          Respiratory rate     :

Surgical history                        :

 

Medications                             :

 

 

Family history              :

 

 

 

Lab investigations                    :            Hb                               :

                                                            ESR                             :

                                                            Blood sugar (F)            :

                                                            Blood sugar (PP)          :

                                                            Rheumatoid Factor       :

Diagnostic tests                        :           CT                                            -                      

                                                            MRI                                         -

                                                            Bone scan                                -

                                                            EMG                                        -

                                                            Nerve conduction studies           -

 

Pain Assessment          :

            Area of Pain                :

Nature of Pain             :

            Chronology of Pain      :

            Aggravating Factors     :

Relieving Factors         :

Visual Analog Scale     :

 


            1          2          3          4          5          6          7          8          9          10

 

Range of Motion          :

            AROM             :           Flexors                         :          

                                                Extensors         :

            PROM              :           Flexors             :

                                                Extensors         :

End-Feel                      :

 

Muscle Power              :

 

Sensory Assessment    :

            Superficial Sensations  :

            Deep Sensations          :

Deep Tendon Reflexes            :

 

Special Tests                :

 

 

Provisional Diagnosis  :

 

 

Follow Up:

 

 

 

1 comment:

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Blood Grouping with Rh Typing
ESR
Fasting Blood Glucose (FBS)
Post Lunch Blood Glucose (PLBS)
Lipid Profile
Glycosylated Haemoglobin (HbA1c)
Urea
Complete Urine Examination (CUE)
Creatinine Serum
Thyroid Stimulating Hormone (TSH)
Calcium
HBsAg
LFT
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Ultrasound - Abdomen & Pelvis
X-Ray - Chest PA View
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