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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
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Occupation Type *
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Designation
Nature of Work
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Active
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Vitals
HEIGHT
WEIGHT
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PR
TEMP
SPO2
Other Health Issues & Treatment History
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History of Present Complaints
5+ yrs BL knee pain - OA knee
Onset
Sudden
Insidious
Gradual
Treatment Taken
Multiple consultations and treatments
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Blue Physiotherapy - old clinic for Lumbar radiculopathy
Update
Present Complaints
Pain in low back - radiculopathy Left side - ADL - brief standing - walking Pain in BL knee - Prolonged walking - stairs up and down Breathlessness even during a continuous conversation
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
19 - 20 - 38 -40 - 42 - 44
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
Pain in all sides of BL knee
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
-
+ Add MMT
Special Tests
Special Test 1
Special Test 2
Remarks
BL Genu varum - Pain even a slight touch - Severe tenderness - Lumbar radiculopathy symptoms on left side WARNING: Dont over do - watch the patient breathing often, as she suffers from cardiac problem and breathlessness even in minimal Physical exertion FOCUS: BL knee ROM - Activation of Proximal lower limb muscles - Spinal mobility - Slight cardio(Low intensity - Low impact cardio E.g.; Cycling)
Diagnosis
Patient Goals & Concerns
Physiotherapy Goals
Short Term Goals
Long Term Goals
Action
-
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Further Referral (if needed)
Nil
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
home programe
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2
home programe
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3
home programe
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4
home programe
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5
home programe
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6
home programe
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home programe
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home programe
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home programe
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14
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17
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Date
Remarks
Weekly 3 sessions x 6 weeks x Rs.900/-
Update
