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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
Kosakulam
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+ days LBA with associated pain in Left Gluteals / Hamstrings / Calf muscle
Onset
Sudden
Insidious
Gradual
Treatment Taken
Ramya hospital - Dr Durairaj, Neuro
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
1st episode - One session in Ramya hospital - IFT Left lower bag
Update
Present Complaints
Pain in Low back / Gluteals / Hamstrings / calf Pain in - sitting / standing / walking
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
36-37-38-40-42
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
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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
-
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Special Tests
Special Test 1
Special Test 2
Remarks
Bilateral Hamstrings tightness As patient is preferring Ramya hospital's prescribed treatment, she is taking only 4 days continuous treatment Our suggestion: 3 sessions per week for 4 weeks
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
Educate well
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2
-
3
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4
-
5
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6
Modified
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7
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8
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9
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10
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11
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12
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13
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14
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Date
Remarks
4 sessions x per session Rs.800
Update
