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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
Address
Samayanallur
Occupation Type *
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Designation
Nature of Work
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Active
Desktop
Field
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Vitals
HEIGHT
WEIGHT
BP
PR
TEMP
SPO2
Other Health Issues & Treatment History
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History of Present Complaints
Right shoulder pain - 9+ months ago 1st episode. Pain onset slow - increased with regular gym and shuttle badminton Right knee - 4 yrs - Fall from bike
Onset
Sudden
Insidious
Gradual
Treatment Taken
No
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Update
Present Complaints
Pain in Right shoulder along the joint line with slight pain on the right neck Sometimes on the right scapula Wakeup pain Pain settled with 4months of rest - No Shuttle, no gym Re-occured with warm up and pushups after 4 months Pain in Shoulder flexion with palms facing up Right knee - Lateral part pain + and - 6 to 8 inches Pain after play
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
Pain on shoulder joint line
Pain Scale
Worst
Same
Better
VAS
At Worst
At Best
Pain Type
Nociceptive
Neuropathic
Nociplastic
Skin Colour
Scar
Adherent
Non-Adherent
No Scar
Swelling
Soft Fluctuating
Leathery
Tough
Dry
Tened
Hard
Boggy
Spongy
Thick
8 to 24 Hours of Injury
Tenderness
Grade I
Grade II
Grade III
Grade IV
Remarks
Joint line tenderness
Update
Edit - Page 3
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Patient Management
Edit - Page 3
ROM
AROM
Movement
Side
Part
Plane
Available Range
Pain Starts
Action
Select
Left
Right
Select
Neck
Wrist
Shoulder
Elbow
Spine
Hip
Knee
Ankle
Select
Sagittal
Frontal
Transverse
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PROM
Movement
Side
Part
Plane
Available Range
Pain Starts
Action
Select
Left
Right
Select
Neck
Wrist
Shoulder
Elbow
Spine
Hip
Knee
Ankle
Select
Sagittal
Frontal
Transverse
-
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End Feel
Soft
Firm
Hard
Empty
MMT
-
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Special Tests
Special Test 1
Special Test 2
Remarks
Range is normal
Diagnosis
Patient Goals & Concerns
Physiotherapy Goals
Short Term Goals
Long Term Goals
Action
-
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Further Referral (if needed)
Nil
Physiotherapist Details
Assessed Physio Name
IAP Membership No.
Treatment In-Charge Name
IAP Membership No.
Update
Electrotherapy
Modality
Site
Details
Date
Remarks
Action
-
-
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Supportive Techniques
Technique
Details
Date
Remarks
Action
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Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
-
2
-
3
-
4
-
5
-
6
-
7
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Date
Remarks
3 sessions x 4 to 6 weeks
Update
