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  :

 

 

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