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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
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HEIGHT
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Other Health Issues & Treatment History
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History of Present Complaints
3+ days - Left low back pain - Sudden onset 4+ months - 1st episode occured suddenly during the 3rd set of deadlift 60kg
Onset
Sudden
Insidious
Gradual
Treatment Taken
Consulted with a Physio - Muscle overlapped
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 Left Low back - In ADL Getting up from chair or into the chair Not referring to adjacent areas
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
36 - Left SIJ
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
Left SIJ
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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
FOCUS: Left SIJ mobility - LPHC strength 15 July 2026 - Patient attended single session and stopped treatment as he felt recovered. Came back today after a session of swimming with friends pain got re-occured. Pain intensity is comparitively less than the previous episode.
Diagnosis
Patient Goals & Concerns
Physiotherapy Goals
Short Term Goals
Long Term Goals
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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
-
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Supportive Techniques
Technique
Details
Date
Remarks
Action
4 sessions per week x 2 weeks
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Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
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Date
Remarks
Fee Rs.1500 per session Use rPMS and FMS all the treatment sessions
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