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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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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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ROM Knee flexion RIGHT
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ROM Knee extension LEFT
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ROM Knee extension RIGHT
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ROM Straight leg raise LEFT
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ROM Straight leg raise RIGHT
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STRENGTH: Hamstrings LEFT
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STRENGTH: Hamstrings RIGHT
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STRENGTH: Quads LEFT
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STRENGTH: Quads RIGHT
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STRENGTH: Heel raises LEFT
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STRENGTH: Heel raises RIGHT
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STRENGTH: Quarter squats LEFT
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STRENGTH: Quarter squats RIGHT
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PALPATION
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TESTING
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VMO RECRUITMENT
• • •
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PROBLEMS
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GOALS
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TREATMENT PLAN
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