Subjective
|
|
Patient _______
|
|
Date of Onset
|
MOI
|
Current Pain Level
|
Location
• • •
|
Best Pain Level
|
|
Worst Pain Level
|
|
Level of function prior to injury
|
|
Current functional deficits include:
• • •
|
Additional functional limitations include:
|
Overall Health
|
|
Objective
|
|
Observation
|
|
Upper extremity standing posture
• • •
|
|
Seated posture
• • •
|
|
Overhead reaching
• • •
|
|
Active Range of Motion
|
|
Thoracic flexion AROM
• • •
|
Thoracic extension AROM
• • •
|
Right thoracic rotation AROM
• • •
|
Left thoracic rotation AROM
• • •
|
Right thoracic sidebend AROM
• • •
|
Left thoracic sidebend AROM
• • •
|
Lumbar flexion AROM
• • •
|
Lumbar extension AROM
• • •
|
Right lumbar sidebend AROM
• • •
|
Left lumbar sidebend AROM
• • •
|
Right lumbar rotation AROM
• • •
|
Left lumbar rotation AROM
• • •
|
Cervical flexion AROM
• • •
|
Cervical extension AROM
• • •
|
Right cervical rotation AROM
• • •
|
Left cervical rotation AROM
• • •
|
Right cervical sidebend AROM
• • •
|
Left cervical sidebend AROM
• • •
|
Right scapular upward rotation AROM
• • •
|
Left scapular upward rotation AROM
• • •
|
Right scapular protraction AROM
• • •
|
Left scapular protraction AROM
• • •
|
Right shoulder scaption AROM
• • •
|
Left shoulder scaption AROM
• • •
|
Right shoulder external rotation at neutral AROM
• • •
|
Left shoulder external rotation at neutral AROM
• • •
|
Right Hand Behind Head
• • •
|
Left Hand Behind Head
• • •
|
Right Hand Behind Back
• • •
|
Left Hand Behind Back
• • •
|
Passive Range of Motion
|
|
Right hip extension PROM
• • •
|
Left hip extension PROM
• • •
|
Right hip flexion PROM
• • •
|
Left hip flexion PROM
• • •
|
Cervical flexion PROM
• • •
|
Cervical extension PROM
• • •
|
Right cervical rotation PROM
• • •
|
Left cervical rotation PROM
• • •
|
Right cervical sidebend PROM
• • •
|
Left cervical sidebend PROM
• • •
|
Right shoulder scaption PROM
• • •
|
Left shoulder scaption PROM
• • •
|
Right shoulder external rotation at neutral PROM
• • •
|
Left shoulder external rotation at neutral PROM
• • •
|
Strength
|
|
Right gluteus maximus
|
Left gluteus maximus
|
Right gluteus medius
|
Left gluteus medius
|
7 stage abdominal strength testing
|
Trunk extensors
|
Right latissimus dorsi
|
Left latissimus dorsi
|
Right serratus anterior
|
Left serratus anterior
|
Right lower trapezius
|
Left lower trapezius
|
Right middle trapezius
|
Left middle trapezius
|
Right rhomboids
|
Left rhomboids
|
Deep cervical flexors
|
|
Right pectoralis major
|
Left pectoralis major
|
Right supraspinatus
|
Left supraspinatus
|
Right infraspinatus
|
Left infraspinatus
|
Joint Mobility
|
|
Right Hip Anterior Glide
|
Left Hip Anterior Glide
|
Right Hip Distraction
|
Left Hip Distraction
|
Right L1 Unilateral PA
• • •
|
Left L1 Unilateral PA
• • •
|
Right L2 Unilateral PA
• • •
|
Left L2 Unilateral PA
• • •
|
Right L3 Unilateral PA
• • •
|
Left L3 Unilateral PA
• • •
|
Right L4 Unilateral PA
• • •
|
Left L4 Unilateral PA
• • •
|
Right L5 Unilateral PA
• • •
|
Left L5 Unilateral PA
• • •
|
Lower Thoracic Central PA
• • •
|
Mid Thoracic Central PA
• • •
|
Right Thoracic Unilateral PA
• • •
|
Left Thoracic Unilateral PA
• • •
|
Right Rib Springs
• • •
|
Left Rib Springs
• • •
|
Right 1st Rib Inferior Glide
• • •
|
Left 1st Rib Inferior Glide
• • •
|
Right CTJ Side Glide
• • •
|
Left CTJ Side Glide
• • •
|
Right Cervical Facet Upglide Mobility
• • •
|
Left Cervical Facet Upglide Mobility
• • •
|
Right OA Posterior Glide with Traction
• • •
|
Left OA Posterior Glide with Traction
• • •
|
Right Scapular Depression Glide
• • •
|
Left Scapular Depression Glide
• • •
|
Right Scapular Posterior Tipping Glide
• • •
|
Left Scapular Posterior Tipping Glide
• • •
|
Right GHJ Posterior Glide
• • •
|
Left GHJ Posterior Glide
• • •
|
Right GHJ Inferior Glide
• • •
|
Left GHJ Inferior Glide
• • •
|
Special Tests
|
|
Vertebrobasilar Insufficiency (VBI) Test
|
Tectorial Membrane Test
|
Right Alar Ligament Test
|
Left Alar Ligament Test
|
Right Sharp-Purser Test
|
Left Sharp-Purser Test
|
Right Spurling's Test
|
Left Spurling's Test
|
Cervical Compression Test
|
Cervical Distraction Test
|
Right cervical quadrant test
|
Left cervical quadrant test
|
Right CRLF
|
Left CRLF
|
Right supine pectoral length deficit test
|
Left supine pectoral length deficit test
|
Right scapular assist test
• • •
|
Left scapular assist test
• • •
|
Right empty can (Jobe) test
|
Left empty can (Jobe) test
|
Right drop arm test
|
Left drop arm test
|
Right Hawkins-Kennedy test
|
Left Hawkins-Kennedy test
|
Right Neer's test
|
Left Neer's test
|
Right painful arc test
• • •
|
Left painful arc test
• • •
|
Right biceps load II test
|
Left biceps load II test
|
Right ERLS test
|
Left ERLS test
|
Right belly press test
|
Left belly press test
|
Right shoulder load and shift test
• • •
|
Left shoulder load and shift test
• • •
|
Right shoulder anterior apprehension test
• • •
|
Left shoulder anterior apprehension test
• • •
|
Musculature tender to palpation
• • •
|
Ligament/Tendon TTP
• • •
|
Other objective findings
|
|
Neurological Exam
|
|
Right ULTT
• • •
|
Left ULTT
• • •
|
Right UE dermatomes
• • •
|
Left UE dermatomes
• • •
|
Right UE myotomes
• • •
|
Left UE myotomes
• • •
|
Right UE DTRs
• • •
|
Left UE DTRs
• • •
|
Assessment
|
|
Patient presents with signs and symptoms consistent with_______
|
|
Response to treatment
• • •
|
Rehabilitation Potential
|
Treatment Necessity
|
Discharge to HEP
|
Functional Goals
|
|
Functional Goals
|
Goal Status
|
Functional Goals
|
Goal Status
|
Functional Goals
|
Goal Status
|
Functional Goals
|
Goal Status
|
Functional Goals
|
Goal Status
|
Functional Goals
|
Goal Status
|
Functional Goals
|
Goal Status
|
Functional Goal: Patient will be able to ____
|
Goal Status
|
Functional Goal: Patient will be able to ____
|
Goal Status
|
Impairment Goals
|
|
Strength Goals
|
Goal Status
|
Strength Goals
|
Goal Status
|
Strength Goals
|
Goal Status
|
Strength Goals
|
Goal Status
|
Strength Goals
|
Goal Status
|
Strength Goals
|
Goal Status
|
LE ROM Goals
|
Goal Status
|
LE ROM Goals
|
Goal Status
|
LE ROM Goals
|
Goal Status
|
LE ROM Goals
|
Goal Status
|
LE ROM Goals
|
Goal Status
|
LE ROM Goals
|
Goal Status
|
Visit Treatment Procedures
|
|
Low Complexity Evaluation
|
Minutes
|
Moderate Complexity Evaluation
|
Minutes
|
High Complexity Evaluation
|
Minutes
|
Re-Evaluation
|
Minutes
|
Manual Units
|
Minutes
|
Manual (STM) performed
• • •
|
Additional Manual
|
Therex Units
|
Minutes
|
Ther-Ex performed
• • •
|
Additional Ther-ex
|
Neuro-ed Units
|
Minutes
|
Neuro-ed performed
• • •
|
Additional Neuro-ed
|
Gait Training Units
|
Minutes
|
Gait Performed
• • •
|
Additional Gait Training
|
Ther-Act Units
|
Minutes
|
Ther-Act performed
• • •
|
Additional Ther-Act
|
Medicare E-stim
|
Minutes
|
Electrical stimulation location
• • •
|
|
Plan
|
|
Manual Therapy
|
TherEx
|
Neuro-muscular re-education
|
Therapeutic Activities
|
Treatment Progression
• • •
|
|
Frequency
|
Duration
|
REFERRAL SIGNATURE
|
|