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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
Tirunelveli - Workplace
Occupation Type *
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Government
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Senior Citizen
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Designation
Nature of Work
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Active
Desktop
Field
Travel
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others
Vitals
HEIGHT
WEIGHT
BP
PR
TEMP
SPO2
Other Health Issues & Treatment History
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History of Present Complaints
5+ yrs - Left side sternum pain - Sudden onset, after karla kattai rotations
Onset
Sudden
Insidious
Gradual
Treatment Taken
Multiple investigations and treatments Normal in MRI - Taken 5 times
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
NA
Update
Present Complaints
Pain in Sternum - left side - Pain in ADL - Around junction between the manubrium and body of sternum Pain in Thoracic area exactly posterior to the pain area
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
5 - Sternum
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 side of the sternum junction of manubrium and body
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
-
+ Add PROM
End Feel
Soft
Firm
Hard
Empty
MMT
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Special Tests
Special Test 1
Special Test 2
Remarks
Restriction in Thoracic rotation
Diagnosis
Patient Goals & Concerns
Physiotherapy Goals
Short Term Goals
Long Term Goals
Action
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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
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Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
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Date
Remarks
Update
