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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
Address
Melamadai
Occupation Type *
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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
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History of Present Complaints
15+ yrs LBA - started with local pain progressively lead to radiating pin in Bilateral posterior leg
Onset
Sudden
Insidious
Gradual
Treatment Taken
Dr Durairaj, Neuro Physician - Ramya hospital
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Nil
Update
Present Complaints
Low back pain - Radiating down to Bilateral hamstrings - calf and Achilles tendon Pain in - Lumbar extension Pain - ADL - brief sitting - standing and any activity lasts more than 10min Pain in BILATERAL KNEE during work - RSI
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
36-37-40-41-42-43
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
lumbar region
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
Spinal flexion - Pain on BL Hamstrings Spinal extension - Pain on Lumbar region - Facet joint tenderness / approximation Posterior chain - tight FOCUS: Spinal mobility - Posterior chain strength - Neurodynamics (Sciatic nerve floss)
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
Focus on flat lumbar spine against the wall
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2
Check the symmetry in weight distribution
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3
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4
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5
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6
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19
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Date
Remarks
10 sessions DCT x Rs.1100 = 11000 10 sessions Non DCT x Rs.800 = 8000 / Total Rs.19000 20% concession Rs.15200 for 20 sessions
Update
