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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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Upper extremity standing posture
• • •
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Seated posture
• • •
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Overhead reaching
• • •
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Active Range of Motion
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Thoracic flexion AROM
• • •
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Thoracic extension AROM
• • •
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Right thoracic rotation AROM
• • •
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Left thoracic rotation AROM
• • •
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Right thoracic sidebend AROM
• • •
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Left thoracic sidebend AROM
• • •
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Lumbar flexion AROM
• • •
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Lumbar extension 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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Cervical flexion AROM
• • •
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Cervical extension AROM
• • •
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Right cervical rotation AROM
• • •
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Left cervical rotation AROM
• • •
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Right cervical sidebend AROM
• • •
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Left cervical sidebend AROM
• • •
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Right scapular upward rotation AROM
• • •
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Left scapular upward rotation AROM
• • •
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Right scapular protraction AROM
• • •
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Left scapular protraction AROM
• • •
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Right shoulder scaption AROM
• • •
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Left shoulder scaption AROM
• • •
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Right shoulder external rotation at neutral AROM
• • •
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Left shoulder external rotation at neutral AROM
• • •
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Right Hand Behind Head
• • •
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Left Hand Behind Head
• • •
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Right Hand Behind Back
• • •
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Left Hand Behind Back
• • •
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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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Cervical flexion PROM
• • •
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Cervical extension PROM
• • •
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Right cervical rotation PROM
• • •
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Left cervical rotation PROM
• • •
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Right cervical sidebend PROM
• • •
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Left cervical sidebend PROM
• • •
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Right shoulder scaption PROM
• • •
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Left shoulder scaption PROM
• • •
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Right shoulder external rotation at neutral PROM
• • •
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Left shoulder external rotation at neutral PROM
• • •
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Strength
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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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7 stage abdominal strength testing
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Trunk extensors
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Right latissimus dorsi
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Left latissimus dorsi
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Right serratus anterior
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Left serratus anterior
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Right lower trapezius
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Left lower trapezius
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Right middle trapezius
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Left middle trapezius
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Right rhomboids
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Left rhomboids
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Deep cervical flexors
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Right pectoralis major
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Left pectoralis major
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Right supraspinatus
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Left supraspinatus
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Right infraspinatus
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Left infraspinatus
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Joint 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 L1 Unilateral PA
• • •
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Left L1 Unilateral PA
• • •
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Right L2 Unilateral PA
• • •
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Left L2 Unilateral PA
• • •
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Right L3 Unilateral PA
• • •
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Left L3 Unilateral PA
• • •
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Right L4 Unilateral PA
• • •
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Left L4 Unilateral PA
• • •
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Right L5 Unilateral PA
• • •
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Left L5 Unilateral PA
• • •
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Lower Thoracic Central PA
• • •
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Mid Thoracic Central PA
• • •
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Right Thoracic Unilateral PA
• • •
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Left Thoracic Unilateral PA
• • •
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Right Rib Springs
• • •
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Left Rib Springs
• • •
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Right 1st Rib Inferior Glide
• • •
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Left 1st Rib Inferior Glide
• • •
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Right CTJ Side Glide
• • •
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Left CTJ Side Glide
• • •
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Right Cervical Facet Upglide Mobility
• • •
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Left Cervical Facet Upglide Mobility
• • •
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Right OA Posterior Glide with Traction
• • •
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Left OA Posterior Glide with Traction
• • •
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Right Scapular Depression Glide
• • •
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Left Scapular Depression Glide
• • •
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Right Scapular Posterior Tipping Glide
• • •
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Left Scapular Posterior Tipping Glide
• • •
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Right GHJ Posterior Glide
• • •
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Left GHJ Posterior Glide
• • •
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Right GHJ Inferior Glide
• • •
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Left GHJ Inferior Glide
• • •
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Special Tests
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Vertebrobasilar Insufficiency (VBI) Test
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Tectorial Membrane Test
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Right Alar Ligament Test
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Left Alar Ligament Test
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Right Sharp-Purser Test
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Left Sharp-Purser Test
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Right Spurling's Test
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Left Spurling's Test
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Cervical Compression Test
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Cervical Distraction Test
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Right cervical quadrant test
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Left cervical quadrant test
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Right CRLF
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Left CRLF
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Right supine pectoral length deficit test
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Left supine pectoral length deficit test
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Right scapular assist test
• • •
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Left scapular assist test
• • •
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Right empty can (Jobe) test
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Left empty can (Jobe) test
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Right drop arm test
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Left drop arm test
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Right Hawkins-Kennedy test
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Left Hawkins-Kennedy test
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Right Neer's test
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Left Neer's test
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Right painful arc test
• • •
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Left painful arc test
• • •
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Right biceps load II test
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Left biceps load II test
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Right ERLS test
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Left ERLS test
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Right belly press test
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Left belly press test
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Right shoulder load and shift test
• • •
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Left shoulder load and shift test
• • •
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Right shoulder anterior apprehension test
• • •
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Left shoulder anterior apprehension test
• • •
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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 ULTT
• • •
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Left ULTT
• • •
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Right UE dermatomes
• • •
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Left UE dermatomes
• • •
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Right UE myotomes
• • •
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Left UE myotomes
• • •
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Right UE DTRs
• • •
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Left UE 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 Goals
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Goal Status
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LE ROM Goals
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Goal Status
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LE ROM Goals
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Goal Status
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LE ROM Goals
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Goal Status
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LE ROM Goals
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Goal Status
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LE ROM Goals
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Goal Status
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LE ROM Goals
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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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