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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
/
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INCREASED PAIN ON
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EDEMA
• • •
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Body Diagram
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ROM Knee flexion LEFT
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Knee flexion RIGHT
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Knee extension LEFT
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Knee extension RIGHT
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Straight leg raise LEFT
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Straight leg raise RIGHT
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STRENGTH Hamstrings LEFT
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Hamstrings RIGHT
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Quads LEFT
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Quads RIGHT
/
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Heel raises LEFT
/
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Heel raises RIGHT
/
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Quarter squats LEFT
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Quarter squats RIGHT
/
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PALPATION
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TEST: Ligaments
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TEST: Balance
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TEST: Patellar tracking
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TEST: Patellar compression
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TEST: VMO recruitment
• • •
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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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PROBLEM 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 4
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TODAY'S TREATMENT
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Duration to Achieve Goals
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Provider
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