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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 limitation 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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Seated posture
• • •
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Overhead reaching
• • •
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Active Range of Motion
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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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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 shoulder scaption AROM
• • •
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Left shoulder scaption AROM
• • •
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Passive Range of Motion
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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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Strength
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Deep cervical flexors
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Cervical extensors
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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 rhomboids
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Left rhomboids
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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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Mid Thoracic Central PA
• • •
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Upper Thoracic Central PA
• • •
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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 Cervical Facet Downglide Mobility
• • •
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Left Cervical Facet Downglide 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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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 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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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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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 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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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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