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Referral
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Medical Diagnosis
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Physical Therapy Diagnosis:
• • •
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History of Present Condition
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Medical History
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Accident date
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General Health status:
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Surgery date
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Chief complaints:
• • •
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Social History
• • •
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Employment Status
• • •
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Work Activities/Limitations
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Surgical History
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Medications
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Prior Care
• • •
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*BMI normal
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*Balance-no risk
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*BMI high
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*Balance: risk of falls + plan
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*BMI low
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*Fall screening not appropriate
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Pain: aggravated by
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pain eased by
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Current pain
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best pain
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Worst pain
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*Body Chart
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Red Flags
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Oswestry
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NDI
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LEFS
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DASH
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Work DASH
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Sports/Arts DASH
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Optimal Scale
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ABC scale
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*PSFS
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TMJ scale
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*Current Functional Impairment
• • •
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*Projected Impairment restriction
• • •
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Posture
• • •
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Posture comment
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Gait
• • •
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Gait comment
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Palpation: tenderness
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tenderness list
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Palpation: atrophy
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atrophy list
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Palpation: trigger points
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trigger point list
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Palpation: spasm
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spasm list
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Abnormal Spinal ROM measures:
• • •
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Extend
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Extension- pain
• • •
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Flex
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Flexion- pain
• • •
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L Rotation
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L Rotation- pain
• • •
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R Rotation
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R Rotation- pain
• • •
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L lateral flexion
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L Lateral flex- pain
• • •
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R Lat Flex
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R Lateral Flex- pain
• • •
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Combined movement testing:
• • •
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Normal peripheral joint ROM
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Abnormal peripheral Joint ROM
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Strength to MMT is normal.
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Abnormal strength findings:
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Manual Therapy Exam findings:
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Neuro Vascular exam:
• • •
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Abnormal Neuro exam findings:
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SFMA
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Assessment
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Comorbidities
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