|
Subjective
|
Time
|
|
History
|
Pain Low
• • •
|
|
Pain high
• • •
|
Increased Pain on...
|
|
Body Diagram
|
|
|
|
|
|
Objective
|
|
|
Dorsiflexion Test Left
• • •
|
Dorsiflexion test right
• • •
|
|
ROM: Ankle dorsiflexion LEFT
|
Dorsiflexion RIGHT
|
|
Plantarflexion LEFT
|
Plantarflexion RIGHT
|
|
Inversion LEFT
|
Inversion RIGHT
|
|
Eversion LEFT
|
Eversion RIGHT
|
|
1st MTP Extension LEFT
|
1st MTP Extension RIGHT
|
|
Lateral Tibial Glide Left
• • •
|
Lateral Tibial Glide Right
• • •
|
|
Left DF Strength
• • •
|
Right DF Strength
• • •
|
|
L Plantarflexion Strength
• • •
|
Right PF Strength
• • •
|
|
Left Inversion Strength
• • •
|
Right Inversion Strength
• • •
|
|
Left Eversion Strength
• • •
|
Right Eversion Strength
• • •
|
|
Heel raises LEFT
|
Heel raises RIGHT
|
|
Left Glute Max Strength
• • •
|
Right Glute Max Strength
• • •
|
|
Left Glute Med Strength
• • •
|
Right Glute Med Strength
• • •
|
|
Palpation
|
Balance
|
|
Negative Specials
• • •
|
Positive Special Tests
• • •
|
|
Other Tests
|
Foot/toe deformities
• • •
|
|
Assessment
|
|
|
Assessment:
|
Rehab potential
|
|
Problem 1
|
Problem 2
|
|
Problem 3
|
Problem 4
|
|
Problem 5
|
|
|
Goal 1
|
Goal 2
|
|
Goal 3
|
Goal 4
|
|
Goal 5
|
|
|
Plan
|
|
|
Treatment Frequency
• • •
|
Treatment Duration
• • •
|
|
Today's Treatment
|
Treatment Plan
|
|
Today's Treatment: Manual
|
Exercises
|
|
Self Care
|
Home Exercise Program
|
|
MD Signature
|
|
