|
Visit Number
|
Referral
|
|
Medical Diagnosis
|
PT treatment Diagnosis
|
|
Time In
|
Time Out
|
|
Certification Period
|
|
|
Subjective:
|
|
|
History of Present Condition
• • •
|
Medical History
|
|
Accident date
|
General Health status:
|
|
Surgery date
|
|
|
Chief complaints:
• • •
|
Chief Complaints Subjective
|
|
Social History
• • •
|
|
|
Employment Status
• • •
|
Work Activities/Limitations
|
|
Surgical History
|
Medications
|
|
Prior Care
• • •
|
|
|
Complicating Factors
• • •
|
Other
|
|
Medical History Review
• • •
|
Medical Status
|
|
*BMI normal
|
*Balance-no risk
|
|
*BMI high
|
*Balance: risk of falls + plan
|
|
*BMI low
|
*Fall screening not appropriate
|
|
Pain: aggravated by
|
pain eased by
|
|
Current pain
|
best pain
|
|
Worst pain
|
*Body Chart
|
|
Current Pain
|
Best Pain
|
|
Worst Pain
|
|
|
Red Flags
|
|
|
Oswestry
|
NDI
|
|
LEFS
|
DASH
|
|
*PSFS
|
Berg Balance Scale
|
|
Patient Goals
|
|
|
*Current Functional Impairment
• • •
|
*Projected Impairment restriction
• • •
|
|
Objective:
|
|
|
Objective Free Write
|
|
|
Posture
• • •
|
Posture comment
|
|
Gait
• • •
|
Gait comment
|
|
Palpation:
|
tenderness/pain list
|
|
Spinal ROM measures:
• • •
|
|
|
Extension
|
Extension- pain
• • •
|
|
Flexion
|
Flexion- pain
• • •
|
|
L Rotation
|
L Rotation- pain
• • •
|
|
R Rotation
|
R Rotation- pain
• • •
|
|
L lateral flexion
|
L Lateral flex- pain
• • •
|
|
R Lat Flex
|
R Lateral Flex- pain
• • •
|
|
ROM additional Comments
|
|
|
|
|
|
Normal peripheral joint ROM
|
Abnormal peripheral Joint ROM
|
|
Strength to MMT is normal.
|
Abnormal strength findings:
|
|
Manual Therapy Exam findings:
|
|
|
|
|
|
Neuro Vascular exam:
• • •
|
Abnormal Neuro exam findings:
|
|
Assessment
|
|
|
Assessment
|
|
|
Patient Education
|
|
|
Goals
|
|
|
Type of Goal
• • •
|
Goal 1
|
|
Type of Goal
|
Goal 2
|
|
Type of Goal
|
Goal 3
|
|
Type of Goal
|
Goal 4
|
|
Type of Goal
|
Goal 5
|
|
Type of Goal
|
Goal 6
|
|
Plan
|
|
|
Plan
|
|
|
Frequency
|
Duration
|
|
Treatment Provided
• • •
|
|
