|
History of present condition
|
Primary Concern/Chief complaint
|
|
Prior Level of Functional
|
|
|
Self Care
• • •
|
Comments
|
|
Mobility: Walking & Moving Around
• • •
|
Comments
|
|
Changing & Maintaining Body Position
• • •
|
Comments
|
|
Carrying, Moving & Handling Objects
• • •
|
Comments
|
|
Current Functional Limitations
|
|
|
Self Care
• • •
|
Comments
|
|
Mobility: Walking & Moving Around
• • •
|
Comments
|
|
Changing & Maintaining Body Position
• • •
|
Comments
|
|
Carrying, Moving & Handling Objects
• • •
|
Comments
|
|
Pain scale
|
|
|
Location
|
|
|
Best (NT-Not tested, 0-None, 5-Moderate, 10-Extreme)
|
|
|
Worst (NT-Not tested, 0-None, 5-Moderate, 10-Extreme)
|
|
|
Current (NT-Not tested, 0-None, 5-Moderate, 10-Extreme)
|
|
|
Aggravating factors
• • •
|
Medical History Review
|
|
Diagnostic imaging
|
Medical history review
|
|
Inspection
|
Outcome measurement tools
• • •
|
|
Upper Extremity Quick DASH - Instructions
|
|
|
Please rate your pain level with activity
|
|
|
How satisfied are you with the level of care and service provided
|
|
|
Please rate your progress with functional activities from start of therapy to this point in time
|
|
|
At this point in your treatment, have your therapy goals been met?
|
|
|
Please rate your ability to do the following activities in the last week
|
|
|
Open a tight or new jar
|
|
|
Do heavy household chores (e.g., wash walls, floors)
|
|
|
Carry a shopping bag or briefcase
|
Wash your back
|
|
Use a knife to cut food
|
|
|
Recreational activities in which you take some force or impact through your arm, shoulder or hand(e.g.golf,hammering,tennis,etc)
|
|
|
During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities
|
|
|
During the past week,were you limited in your work/other regular daily activities as a result of your arm,shoulder/hand problem
|
|
|
Arm, shoulder or hand pain
|
|
|
Tingling (pins and needles) in your arm, shoulder or hand
|
|
|
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand
|
|
|
Neck Disability Index Questionnaire - Instructions
|
|
|
Patient Satisfaction
|
Please rate your pain level with activity
|
|
How satisfied are you with the level of care and service provided
|
|
|
Please rate your progress with functional activities from start of therapy to this point in time
|
|
|
At this point in your treatment, have your therapy goals been met?
|
|
|
Pain Intensity
|
Personal Care (Washing, Dressing etc.)
|
|
Lifting
|
Headache
|
|
Recreation
|
Reading
|
|
Work
|
Sleeping
|
|
Concentration
|
Driving
|
|
Scoring
|
|
|
Please read below and enter the scores
|
|
|
Total score = SUM (points for all 10 sections)
|
|
|
Disability in percent = (total score) / 50 * 100
|
|
|
If not all of the questions are answered then disability in percent = (total score) / (5 * (number of questions answered)) * 100
|
|
|
Minimal Detectable Change (90% confidence): 5 points or 10%
|
|
|
Interpretation, please read below
|
|
|
Oswestry Low Back Pain Disability Questionnaire
|
|
|
Patient Satisfaction
|
Please rate your pain level with activity
|
|
How satisfied are you with the level of care and service provided
|
|
|
Please rate your progress with functional activities from start of therapy to this point in time
|
|
|
At this point in your treatment, have your therapy goals been met?
|
|
|
Pain Intensity
|
Personal Care (Washing, Dressing, etc.)
|
|
Lifting
|
Walking
|
|
Sitting
|
Standing
|
|
Sleeping
|
Social Life
|
|
Traveling
|
Employment / Homemaking
|
|
Scoring
|
|
|
Total score = SUM (points for all 10 sections)
|
|
|
Disability in percent = (total score) / 50 * 100
|
|
|
If not all of the questions are answered then disability in percent = (total score) / (5 * (number of questions answered)) * 100
|
|
|
Lower Extremity Functional Scale
|
|
|
Patient Satisfaction
|
Please rate your pain level with activity
|
|
How satisfied are you with the level of care and service provided
|
|
|
Please rate your progress with functional activities from start of therapy to this point in time
|
|
|
At this point in your treatment, have your therapy goals been met?
|
|
|
Today do you or would you have any difficulty at all with these activities?
|
|
|
Any of your usual work, housework or school activities
|
|
|
Your usual hobbies, recreational or sporting activities
|
|
|
Getting into or out of the bath
|
Walking between rooms
|
|
Putting on your shoes or socks
|
Squatting
|
|
Lifting an object, like a bag of groceries from the floor
|
|
|
Performing light activities around your home
|
|
|
Performing heavy activities around your home
|
|
|
Getting into or out of a car
|
Walking 2 blocks
|
|
Walking a mile
|
|
|
Going up or down 10 stairs (about 1 flight of stairs)
|
|
|
Standing for 1 hour
|
Sitting for 1 hour
|
|
Running on even ground
|
Running on uneven ground
|
|
Making sharp turns while running fast
|
Hopping
|
|
Rolling over in bed
|
|
|
LEFS score instruction, please read below
|
|
|
LEFS score = SUM (points for all 20 activities) Interpretation
|
|
|
Percent of maximal function instruction, please read below
|
|
|
Percent of maximal function = (LEFS score) / 80 * 100 Performance
|
|
|
References: Binkley JM Stratford PW et al, please read below
|
|
|
Range of Motion - Cervical profile ROM
|
|
|
AROM
|
No Limitations Noted
|
|
Subcranial AROM
|
Forward Nod (flexion)
• • •
|
|
Backward Nod (extension)
• • •
|
Right Side Bending
• • •
|
|
Left Side Bending
• • •
|
Right Rotation
• • •
|
|
Left Rotation
• • •
|
Cervical AROM
|
|
Forward Bending
• • •
|
Backward Bending
• • •
|
|
Right Rotation
• • •
|
Left Rotation
• • •
|
|
Right Side Bending
• • •
|
Left Side Bending
• • •
|
|
Shoulder AROM
|
|
|
Shoulder AROM - Right
|
|
|
Flexion
• • •
|
Scaption
• • •
|
|
Abduction
• • •
|
Extension
• • •
|
|
Horizontal Abduction
• • •
|
Horizontal Adduction
• • •
|
|
Shoulder AROM - Left
|
|
|
Flexion
• • •
|
Scaption
• • •
|
|
Abduction
• • •
|
Extension
• • •
|
|
Horizontal Abduction
• • •
|
Horizontal Adduction
• • •
|
|
Movement Based Test Movements Cervical
|
Movement Based Test Movements Thoracic
|
|
Range of Motion - THORACIC/Back ROM profile
|
|
|
No Limitations Noted
|
Cervical AROM
|
|
Forward Bending
• • •
|
Backward Bending
• • •
|
|
Right Rotation
• • •
|
Left Rotation
• • •
|
|
Right Side Bending
• • •
|
Left Side Bending
• • •
|
|
|
|
|
Thoracic AROM Sitting with Passive Overpressure
|
|
|
Apply to All
• • •
|
Forward Bending
• • •
|
|
Backward Bending
• • •
|
Right Rotation
• • •
|
|
Left Rotation
• • •
|
Right Side Bending
• • •
|
|
Left Side Bending
• • •
|
Thoracic AROM Standing
|
|
Apply to All
• • •
|
Forward Bending
• • •
|
|
Backward Bending
• • •
|
Right Rotation
• • •
|
|
Left Rotation
• • •
|
Right Side Bending
• • •
|
|
Left Side Bending
• • •
|
Lumbar AROM
|
|
Apply to All
• • •
|
Forward Bending
• • •
|
|
Backward Bending
• • •
|
Right Rotation
• • •
|
|
Left Rotation
• • •
|
Right Side Bending
• • •
|
|
Left Side Bending
• • •
|
|
|
Range of Motion - Shoulder ROM profile
|
|
|
No Limitations Noted
|
Cervical AROM
|
|
Forward Bending
• • •
|
Backward Bending
• • •
|
|
Right Rotation
• • •
|
Left Rotation
• • •
|
|
Right Side Bending
• • •
|
Left Side Bending
• • •
|
|
Shoulder AROM
|
|
|
Shoulder AROM - Right
|
|
|
Apply to All
• • •
|
|
|
Flexion
• • •
|
Scaption
• • •
|
|
Abduction
• • •
|
Extension
• • •
|
|
Horizontal Abduction
• • •
|
Horizontal Adduction
• • •
|
|
Shoulder AROM - Left
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Scaption
• • •
|
Abduction
• • •
|
|
Extension
• • •
|
Horizontal Abduction
• • •
|
|
Horizontal Adduction
• • •
|
Elbow AROM
|
|
Elbow AROM - Right
|
|
|
Extension
• • •
|
Flexion
• • •
|
|
Supination
• • •
|
Pronation
• • •
|
|
Elbow AROM - Left
|
|
|
Extension
• • •
|
Flexion
• • •
|
|
Supination
• • •
|
Pronation
• • •
|
|
Wrist AROM
|
|
|
Wrist AROM - Right
|
|
|
Extension
• • •
|
Flexion
• • •
|
|
Wrist AROM - Left
|
|
|
Extension
• • •
|
Flexion
• • •
|
|
Range of Motion - Knee ROM Profile
|
|
|
No Limitations Noted
|
Hip AROM
|
|
Hip AROM - Right
|
|
|
Flexion
• • •
|
Extension
• • •
|
|
Abduction
• • •
|
Adduction
• • •
|
|
Hip AROM - Left
|
|
|
Flexion
• • •
|
Extension
• • •
|
|
Abduction
• • •
|
Adduction
• • •
|
|
Knee AROM
|
|
|
Knee AROM - Right
|
|
|
Flexion
• • •
|
Extension
• • •
|
|
Knee AROM - Left
|
|
|
Flexion
• • •
|
Extension
• • •
|
|
Ankle AROM
|
|
|
Ankle AROM - Right
|
|
|
Dorsiflexion at 0 Knee Flexion
• • •
|
Dorsiflexion at 90 Knee Flexion
• • •
|
|
Plantarflexion
• • •
|
Inversion
• • •
|
|
Eversion
• • •
|
Additional comments
|
|
Ankle AROM - Left
|
|
|
Dorsiflexion at 0 Knee Flexion
• • •
|
Dorsiflexion at 90 Knee Flexion
• • •
|
|
Plantarflexion
• • •
|
Inversion
• • •
|
|
Eversion
• • •
|
Additional comments
|
|
Range of Motion - Lumbar ROM profile
|
|
|
Thoracic AROM Sitting with Passive Overpressure
|
|
|
Apply to All
• • •
|
Forward Bending
• • •
|
|
Backward Bending
• • •
|
Right Rotation
• • •
|
|
Left Rotation
• • •
|
Right Side Bending
• • •
|
|
Left Side Bending
• • •
|
Thoracic AROM Standing
|
|
Apply to All
• • •
|
Forward Bending
• • •
|
|
Backward Bending
• • •
|
Right Rotation
• • •
|
|
Left Rotation
• • •
|
Right Side Bending
• • •
|
|
Left Side Bending
• • •
|
Lumbar AROM
|
|
Apply to All
• • •
|
Forward Bending
• • •
|
|
Backward Bending
• • •
|
Right Rotation
• • •
|
|
Left Rotation
• • •
|
Right Side Bending
• • •
|
|
Left Side Bending
• • •
|
Hip AROM
|
|
Hip AROM - Right
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
Abduction
• • •
|
|
Adduction
• • •
|
|
|
Hip AROM - Left
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
Abduction
• • •
|
|
Adduction
• • •
|
Knee AROM
|
|
Knee AROM - Right
|
|
|
Flexion
• • •
|
Extension
• • •
|
|
Knee AROM - Left
|
|
|
Flexion
• • •
|
Extension
• • •
|
|
Ankle AROM
|
|
|
Ankle AROM - Right
|
|
|
Dorsiflexion at 0 Knee Flexion
• • •
|
Dorsiflexion at 90 Knee Flexion
• • •
|
|
Plantarflexion
• • •
|
Inversion
• • •
|
|
Eversion
• • •
|
|
|
Ankle AROM - Left
|
|
|
Dorsiflexion at 0 Knee Flexion
• • •
|
Dorsiflexion at 90 Knee Flexion
• • •
|
|
Plantarflexion
• • •
|
Inversion
• • •
|
|
Eversion
• • •
|
|
|
Range of Motion - Hip ROM Profile
|
|
|
Hip AROM
|
|
|
Hip AROM - RIght
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
Abduction
• • •
|
|
Adduction
• • •
|
|
|
Hip AROM - Left
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
Abduction
• • •
|
|
Adduction
• • •
|
Knee AROM
|
|
Knee AROM - Right
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
|
|
Knee AROM - Left
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
|
|
Range of Motion - Ankle ROM Profile
|
|
|
Hip AROM
|
|
|
Hip AROM - Right
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
Abduction
• • •
|
|
Adduction
• • •
|
|
|
Hip AROM - Left
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
Abduction
• • •
|
|
Adduction
• • •
|
Knee AROM
|
|
Knee AROM - Right
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
|
|
Knee AROM - Left
|
|
|
Apply to All
• • •
|
Flexion
• • •
|
|
Extension
• • •
|
Ankle AROM
|
|
Ankle AROM - Right
|
|
|
Dorsiflexion at 0 Knee Flexion
• • •
|
Dorsiflexion at 90 Knee Flexion
• • •
|
|
Plantarflexion
• • •
|
Inversion
• • •
|
|
Eversion
• • •
|
|
|
Ankle AROM - Left
|
|
|
Dorsiflexion at 0 Knee Flexion
• • •
|
Dorsiflexion at 90 Knee Flexion
• • •
|
|
Plantarflexion
• • •
|
Inversion
• • •
|
|
Eversion
• • •
|
|
|
Range of Motion - Elbow ROM Profile
|
|
|
Shoulder AROM
|
Apply to All
• • •
|
|
Flexion
• • •
|
Scaption
• • •
|
|
Abduction
• • •
|
Extension
• • •
|
|
Horizontal Abduction
• • •
|
Horizontal Adduction
• • •
|
|
Elbow AROM
|
Apply to All
• • •
|
|
Extension
• • •
|
Flexion
• • •
|
|
Supination
• • •
|
Pronation
• • •
|
|
Wrist AROM
|
Apply to All
• • •
|
|
Extension
• • •
|
Flexion
• • •
|
|
Radial Deviation
• • •
|
Ulnar Deviation
• • •
|
|
Additional Comments
|
|
|
CERVICAL SPECIAL TESTS
|
|
|
Subcranial Passive Vertebral Mobility
|
Cervical Passive Vertebral Mobility
|
|
Passive Vertebral Mobility Thoracic
|
Cervical Quadrant
|
|
Cervical Comp/Dist
|
Spurling's Maneuver
|
|
Alar Ligament Test
|
Alar Ligament Stress
|
|
Work Conditioning
|
MR FAB 4 Worksheet
|
|
Movement Based Provisional Classification
|
Movement Based Principle Of Management
|
|
Additional comments
|
|
|
Strength
|
|
|
Gross muscle test
|
|
|
THORACIC SPINE RIBS SPECIAL TESTS
|
|
|
Yeoman's Test
|
Subcranial Passive Vertebral Mobility
|
|
Cervical Passive Vertebral Mobility
|
Passive Vertebral Mobility Thoracic
|
|
Rib Springing
|
Kemp's Test
|
|
Cervical Quadrant
|
Cervical Comp/Dist
|
|
Bragard's Sign
|
Leg Length
|
|
Alar Ligament
|
Alar Ligament Stress
|
|
Work Conditioning
|
TMR FAB 4 Worksheet
|
|
Movement Based Provisional Classification
|
Movement Based Principle Of Management
|
|
Additional comments
|
|
|
Strength
|
|
|
Gross muscle test
|
|
|
SHOULDER SPECIAL TESTS
|
|
|
Passive Joint Mobility Shoulder
|
Cervical Quadrant
|
|
Cervical Comp/Dist
|
SC Joint
|
|
AC Joint
|
Capsular Pattern
|
|
Impingement
|
GHJ Stability
|
|
Labrum
|
Rotator Cuff
|
|
Speed's Test
|
Yergason's Test
|
|
Ligament Integrity Elbow
|
Spurling's Maneuver
|
|
Alar Ligament Test
|
Alar Ligament Stress
|
|
Work Conditioning
|
TMR FAB 4 Worksheet
|
|
Additional comments
|
|
|
Strength
|
|
|
Gross muscle test
|
|
|
KNEE SPECIAL TEST
|
|
|
Ligament Integrity Ankle
|
Meniscal Integrity Knee
|
|
Flexibility
|
Structural
|
|
Ligament Integrity Knee
|
Leg Length
|
|
Patellofemoral
|
Proprioception/Balance
|
|
Functional
|
Work Conditioning
|
|
TMR FAB 4 Worksheet
|
Additional comments
|
|
Strength
|
|
|
Gross muscle test
|
|
|
LUMBAR SPECIAL TEST
|
|
|
Supine To Sit
|
Flexibility
|
|
Structural
|
Yeoman's Test
|
|
Passive Vertebral Mobility Thoracic
|
Passive Vertebral Mobility Lumbar
|
|
Kemp's Test
|
Sacral Passive Mobility
|
|
Prone SI Gapping
|
Innominate/Sacral Positioning
|
|
Ligament Integrity Knee
|
Sacrotuberous Ligament Stress Test
|
|
Bragard's Sign
|
SI Compression
|
|
SI Distraction
|
Stork Stand SI Mobility Test
|
|
Leg Length
|
Femoral Shear
|
|
Labrum Integrity Hip
|
Patellofemoral
|
|
Proprioception/Balance
|
Functional
|
|
Work Conditioning
|
TMR FAB 4 Worksheet
|
|
Movement Based Provisional Classification
|
Movement Based Principle Of Management
|
|
Additional comments
|
|
|
Strength
|
|
|
Gross muscle test
|
|
|
HIP SPECIAL TEST
|
|
|
Flexibility
|
Structural
|
|
Yeoman's Test
|
Ligament Integrity Knee
|
|
Lasegue's SLR
|
Marching Sign
|
|
Bragard's Sign
|
Leg Length
|
|
Labrum Integrity Hip
|
Patellofemoral
|
|
Proprioception/Balance
|
Functional
|
|
Work Conditioning
|
TMR FAB 4 Worksheet
|
|
Additional comments
|
|
|
Strength
|
|
|
Gross muscle test
|
|
|
ANKLE SPECIAL TESTS
|
|
|
Ligament Integrity Ankle
|
Flexibility
|
|
Structural
|
Passive Joint Mobility
|
|
MTP Joints
|
Midtarsal Joints
|
|
Ligament Integrity Knee
|
Leg Length
|
|
Patellofemoral
|
Proprioception/Balance
|
|
Functional
|
Work Conditioning
|
|
TMR FAB 4 Worksheet
|
Additional comments
|
|
Strength
|
|
|
Gross muscle test
|
|
|
ELBOW SPECIAL TESTS
|
|
|
Passive Joint Mobility Shoulder
|
Passive Joint Mobility Elbow
|
|
Cervical Quadrant
|
Cervical Comp/Dist
|
|
SC Joint
|
AC Joint
|
|
Impingement
|
GHJ Stability
|
|
Labrum
|
Rotator Cuff
|
|
Speed's Test
|
Yergason's Test
|
|
Ulnar Nerve Subluxation
|
Ligament Integrity Elbow
|
|
Milking Sign
|
Spurling's Maneuver
|
|
Work Conditioning
|
TMR FAB 4 Worksheet
|
|
Additional comments
|
|
|
Strength
|
|
|
Gross muscle test
|
|
|
Palpation
|
Comments
|
|
Problem list - Description
|
Patient Clinical Presentation
|
|
Patient Problem
|
Short Term Goals
|
|
Longer Term Goals
|
Frequency
|
|
Duration
|
Plan
|
|
Treatment to be provided
|
|
|
Procedures
• • •
|
Modalities
• • •
|
|
Specialities
• • •
|
Others, please specify here
|
