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