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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
Near Sona Mahal Tiruppalai
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
4+ yrs, Low back pain - Mainly on the right side gluteals Sudden onset - Fell down from a shelf of 3 feet height Inspite of multiple consultations and treatments, Pain is not reduced
Onset
Sudden
Insidious
Gradual
Treatment Taken
Ramya hospital - Dr Durairaj, MD(Paed)., DM(Neuro) Saravana hospital - Female doctor - Dont know the name GRH, Madurai - Ortho
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Saravana hospital - IFT + ILT - Pain increased GRH - IFT
Update
Present Complaints
Pain in Right low back - No pain in Left side Pain referring down gluteals - Around the hip joint - lateral and front thigh - shin - dorsum of foot Unable to do simple domestic activities Most of the time lying in bed - Unable to sit continuously even for 30min
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
37-39-17-19-21
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
Patient complaints of pain mainly around the Gluteals - Lateral and groin and hip joint area
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
10 sessions in 2 weeks
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Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
-
+ Add Row
Date
Remarks
PACKAGE: Single payment, No installments 10 sessions in first 2 weeks = 10 sessions followed by 3 sessions per week x 6 weeks = 18 sessions Total 28 sessions Fee Rs.27,600
Update
