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Chief Complaint
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Mechanism of Injury
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Date of Accident
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History of present condition
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Investigations done
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Medications
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Allergies
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Review of systems
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Skin
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Cardiovascular system
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Pulmonary
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Gastrointestinal
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Neurological
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Genitourinary
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Haematological
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Lymphatics
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Endocrinology
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Psychiatric
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Gynaecological
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Sexual Relations
• • •
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Personal Injury Questions
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Patient was
• • •
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Was patient wearing seat belt
• • •
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Did airbag deploy
• • •
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Area of impact
• • •
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Did patient go to the hospital or urgent care
• • •
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Cuts/contusions
• • •
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Did patients loose consciousness
• • •
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Is the patient working at present?
• • •
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Patient's work requirement
• • •
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Concussion/TBI/PTSD
• • •
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Previous injuries, surgeries, tests and treatment
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Is previous injury/surgery contributory to present complain of pain
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Comments
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SUBJECTIVE
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Pain Assessment
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Location 1
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Pain Scale
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Quality
• • •
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Irritability
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Radiation
• • •
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Location 2
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Pain Scale
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Quality
• • •
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Irritability
|
|
Radiation
• • •
|
|
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Location 3
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Pain Scale
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Quality
• • •
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Irritability
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Radiation
• • •
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Prior Level of Functioning
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Level of Assistance
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Sitting
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Standing
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Walking
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Lifting
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Working
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Self Care
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Current Level of Function
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Level of Assistance
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Sitting
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Standing
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Walking
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Lifting
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Working
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Self Care
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Patient Goals
• • •
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Comments
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OBJECTIVE
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General Physical Exam
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Height
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Weight
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Pulse
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Blood pressure
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Posture
• • •
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Gait
• • •
|
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Neurologic
|
Inspection
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|
Sleep
• • •
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Comments
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|
PT Examination
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Spine/Sacroiliac Joint
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Tenderness
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Trigger points
• • •
|
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Muscle spasm
• • •
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Abdominal Strength
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Lumbar Extensors Strength
|
Range of Motion
|
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Dermatomes
|
Myotomes
|
|
Deep Tendon Reflexes
|
Special Tests
• • •
|
|
Deep neck flexor endurance test
|
|
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Shoulder
|
ST
|
|
Tenderness
|
Trigger points
• • •
|
|
Muscle spasm
• • •
|
Range of Motion
|
|
Manual Muscle Testing
|
Shoulder strength
• • •
|
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Special Tests
• • •
|
Comments
|
|
|
Special Tests
|
|
Elbow
|
|
|
Tenderness
|
Range of Motion
|
|
Manual Muscle Testing
|
Special Tests
|
|
Comments
|
|
|
Hand and Wrist
|
|
|
Tenderness
|
Muscle spasm
• • •
|
|
Range of Motion
|
Manual Muscle Testing
|
|
Special Tests
|
Comments
|
|
Hip
|
|
|
Tenderness
|
Muscle spasm
• • •
|
|
Trigger points
• • •
|
Range of Motion
|
|
Manual Muscle Testing
|
Special Tests
|
|
Comments
|
|
|
Knee
|
|
|
Tenderness
|
Trigger points
• • •
|
|
Muscle spasm
• • •
|
Range of Motion
|
|
Manual muscle Testing
|
Special Tests
• • •
|
|
Comments
|
|
|
Foot and Ankle
|
Special Tests
|
|
Tenderness
|
Trigger points
• • •
|
|
Muscle spasm
• • •
|
Range of Motion
|
|
Manual Muscle Testing
|
Special Tests
|
|
Comments
|
|
|
Outcome Scale 1
|
Outcome scale 2
|
|
Outcome scale 3
|
|
|
ASSESSMENT
|
|
|
PT Diagnosis
|
|
|
PLAN OF CARE
|
|
|
Plan Of Care
• • •
|
Frequency
• • •
|
|
Duration (weeks)
• • •
|
Precautions
|
|
Short Term Goals
• • •
|
Long Term Goals
• • •
|
|
Additional Short term goals
|
Additional Long term goals
|
