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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
Address
EB colony
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Active
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Vitals
HEIGHT
WEIGHT
BP
PR
TEMP
SPO2
Other Health Issues & Treatment History
-
+ Add Row
History of Present Complaints
From 2023, Low back pain confined to the L4 L5 S1 segments - Not referring to the sides or down Pain intensified with T-bar rowing / Good morning exercises
Onset
Sudden
Insidious
Gradual
Treatment Taken
Multiple consultations and treatments Dhanvanthri - 15 days Dr PVR, and Gowtham - 3 months x Not recovered
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Update
Present Complaints
No pain in Daily routines Pain only for the past 2 days in two wheeler riding - STOPPED Deadlift due to pain / Using only RDL Pain mostly on bending activities in associating with loading Pain is commonly on BL Hamstrings
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
Pain in Low back closer to sacrum Pain 6 to 7 in BL Hamstrings
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
Gr.II to Gr.III Pain in L4 and L5 spinous process
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
Muscle Firing: BL hamstrings over firing than gluteals in Firing or recruitment patterns
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
-
-
+ Add Row
Supportive Techniques
Technique
Details
Date
Remarks
Action
-
+ Add Row
Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
-
+ Add Row
Date
Remarks
Weekly 2 sessions x 5 weeks Rs.500 per session
Update
