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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
Bangalore Came to Madurai for holidays
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
6+ months - Low back pain Recent weight gain of 3Kgs in a year 2Yrs - Left patella hairline fracture - Sudden unpredictable pain in knee
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
NA
Update
Present Complaints
Low back pain - ADL Prolonged sitting - Two wheeler ride Left knee pain - Unpredictable - Feeling of instability and imbalance for a second or two
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
36-37 - Coccyx bone
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
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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
-
+ 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
Diagnosis
Patient Goals & Concerns
Physiotherapy Goals
Short Term Goals
Long Term Goals
Action
-
+ Add Goal
Further Referral (if needed)
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
-
2
-
3
-
4
-
5
-
6
-
7
-
+ Add Row
Date
Remarks
One session - Rs.700
Update
