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Subjective
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Patient _______
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Date of Onset
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MOI
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Current Pain Level
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Location
• • •
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Best Pain Level
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Worst Pain Level
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Level of function prior to injury
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Current functional deficits include:
• • •
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Additional functional limitations include:
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Overall Health
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Objective
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Observation
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Lower extremity standing posture
• • •
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Gait
• • •
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Double limb squat
• • •
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Right single limb squat
• • •
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Left single limb squat
• • •
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Right single limb balance
• • •
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Left single limb balance
• • •
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Active Range of Motion
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Thoracic extension AROM
• • •
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Thoracic flexion AROM
• • •
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Right thoracic rotation AROM
• • •
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Left thoracic rotation AROM
• • •
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Right thoracic sidebending AROM
• • •
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Left thoracic sidebending AROM
• • •
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Lumbar extension AROM
• • •
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Lumbar flexion AROM
• • •
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Right lumbar sidebend AROM
• • •
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Left lumbar sidebend AROM
• • •
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Right lumbar rotation AROM
• • •
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Left lumbar rotation AROM
• • •
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Passive Range of Motion
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Right hip extension PROM
• • •
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Left hip extension PROM
• • •
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Right hip flexion PROM
• • •
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Left hip flexion PROM
• • •
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Right hip internal rotation PROM
• • •
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Left hip internal rotation PROM
• • •
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Right hip external rotation PROM
• • •
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Left hip external rotation PROM
• • •
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Right hip abduction PROM
• • •
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Left hip abduction PROM
• • •
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Right hip adduction PROM
• • •
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Left hip adduction PROM
• • •
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Right talocrural joint dorsiflexion PROM
• • •
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Left talocrural joint dorsiflexion PROM
• • •
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Strength
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7 stage abdominal strength testing
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Right gluteus maximus
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Left gluteus maximus
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Right gluteus medius
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Left gluteus medius
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Right hip flexors
• • •
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Left hip flexors
• • •
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Right posterior tibialis
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Left posterior tibialis
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Right peroneals
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Left peroneals
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Joint Mobility
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Thoracic PA Mobility
• • •
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Right Lumbar Unilateral PA Mobility
• • •
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Left Lumbar Unilateral PA Mobility
• • •
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Right Hip Anterior Glide
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Left Hip Anterior Glide
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Right Hip Distraction
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Left Hip Distraction
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Right Talocrural AP Glide
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Left Talocrural AP Glide
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Special Tests
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Prone instability test
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Right lumbar quadrant test
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Left lumbar quadrant test
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Right straight leg raise
• • •
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Left straight leg raise
• • •
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Laslett Cluster for SIJ dysfunction
• • •
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SIJ alignment
• • •
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Sacral positioning
• • •
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FABER test
• • •
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FADER/FAIR/piriformis test
• • •
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Thomas test
• • •
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Ober's test
• • •
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Anterior hip instability with leg raise
• • •
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Musculature tender to palpation
• • •
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Ligament/Tendon TTP
• • •
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Other objective findings
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Neurological Exam
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Right LLTT
• • •
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Left LLTT
• • •
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Right LE dermatomes
• • •
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Left LE dermatomes
• • •
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Right LE myotomes
• • •
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Left LE myotomes
• • •
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Right LE DTRs
• • •
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Left LE DTRs
• • •
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Assessment
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Patient presents with signs and symptoms consistent with_______
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Response to treatment
• • •
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Rehabilitation Potential
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Treatment Necessity
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Discharge to HEP
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Functional Goals
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Functional Goals
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Goal Status
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Functional Goals
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Goal Status
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Functional Goals
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Goal Status
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Functional Goals
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Goal Status
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Functional Goals
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Goal Status
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Functional Goals
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Goal Status
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Functional Goals
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Goal Status
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Functional Goal: Patient will be able to ____
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Goal Status
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Functional Goal: Patient will be able to ____
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Goal Status
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Impairment Goals
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Strength Goals
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Goal Status
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Strength Goals
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Goal Status
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Strength Goals
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Goal Status
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Strength Goals
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Goal Status
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Strength Goals
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Goal Status
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Strength Goal: Patient will demonstrate ____
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Goal Status
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ROM Goals
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Goal Status
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ROM Goals
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Goal Status
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ROM Goals
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Goal Status
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ROM Goals
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Goal Status
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ROM Goals
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Goal Status
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ROM Goal: Patient will demonstrate ____
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Goal Status
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Visit Treatment Procedures
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Low Complexity Evaluation
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Minutes
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Moderate Complexity Evaluation
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Minutes
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High Complexity Evaluation
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Minutes
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Re-Evaluation
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Minutes
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Manual Units
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Minutes
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Manual (STM) performed
• • •
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Additional Manual
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Therex Units
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Minutes
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Ther-Ex performed
• • •
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Additional Ther-ex
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Neuro-ed Units
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Minutes
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Neuro-ed performed
• • •
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Additional Neuro-ed
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Gait Training Units
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Minutes
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Gait Performed
• • •
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Additional Gait Training
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Ther-Act Units
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Minutes
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Ther-Act performed
• • •
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Additional Ther-Act
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Medicare E-stim
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Minutes
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Electrical stimulation location
• • •
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Plan
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Manual Therapy
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TherEx
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Neuro-muscular re-education
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Therapeutic Activities
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Treatment Progression
• • •
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Frequency
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Duration
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REFERRAL SIGNATURE
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