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Patient's Name
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Doctor's Name
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Occupation
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Diagnosis
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Patient's Age
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History
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Pain Initially
/
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Pain now at rest with meds
/
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Increased Pain
• • •
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Edema
• • •
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Body Diagram
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ROM: Shoulder flexion LEFT
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Flexion RIGHT
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Abduction LEFT
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Abduction RIGHT
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External rotation LEFT
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External rotation RIGHT
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Reaching behind LEFT
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Reaching behind RIGHT
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Strength: Shoulder flexion LEFT
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Flexion RIGHT
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Abduction LEFT
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Abduction RIGHT
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External rotation LEFT
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External rotation RIGHT
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Internal rotation LEFT
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Internal rotation RIGHT
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Palpation (tone & tenderness)
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Testing: Impingement test
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Special Test 1
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Special Test 2
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Special Test 3
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Special Test 4
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Special Test 5
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Problems 1
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Problem 2
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Problem 3
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Problem 4
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Problem 5
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Goal 1
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Goal 2
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Goal 3
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Goal 4
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Goal 5
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Rehab Potential
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Treatment Plan 1
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Treatment 2
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Treatment 3
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Treatment Plan 4
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Duration to Achieve Goals
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Today's Treatment
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Provider Name
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