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Physio Review
Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
Address
180-22, Pon Vizha nagar 4th street Surya nagar
Occupation Type *
Select
Government
Non-Government
Senior Citizen
Others
Designation
Nature of Work
Select
Active
Desktop
Field
Travel
House Holder
others
Vitals
HEIGHT
WEIGHT
BP
PR
TEMP
SPO2
Other Health Issues & Treatment History
-
+ Add Row
History of Present Complaints
Regular gym - 6 days / week 1 week - Low back pain - Sudden onset - after a deadlift workout - heard a sound on low back - First time lifted 150 pounds - Pain started in 2nd set
Onset
Sudden
Insidious
Gradual
Treatment Taken
Nil
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Update
Present Complaints
Pain on Left lower back - ADL - Forward bending Prolonged sitting - standing
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
36
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
Update
Edit - Page 3
Dashboard
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
-
+ Add AROM
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
-
+ Add PROM
End Feel
Soft
Firm
Hard
Empty
MMT
-
+ Add MMT
Special Tests
Special Test 1
Special Test 2
Remarks
Pain on Left SIJ in forward bending
Diagnosis
Patient Goals & Concerns
Physiotherapy Goals
Short Term Goals
Long Term Goals
Action
-
+ Add Goal
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
-
-
+ Add Row
Supportive Techniques
Technique
Details
Date
Remarks
Action
-
+ Add Row
Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
-
+ Add Row
Date
Remarks
5 to 6 Alternate sessions rPMS and FMS followed by 3 alternate sessions Total 9 to 10sessions
Update
