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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
Sasi Nagar west Opp to Naveen Bakery
Occupation Type *
Select
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
-
-
+ Add Row
History of Present Complaints
10+ yrs - Neck pain associated BL UL numbness 2+ yrs LBA - associated BL LL numbness 6+ months - Right shoulder pain and stiffness
Onset
Sudden
Insidious
Gradual
Treatment Taken
Multiple treatments - Ortho / Neuro
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 - Neck / LBA / Right shoulder Pain / Radiating pain / Numbness - BL UL and LL Pain - ADL
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
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
Dashboard
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
Lack of mobility - low pain tolerance - Low self esteem FOCUS: Overall mobility - Functional training - Nerve flossing - Education and confidence
Diagnosis
Patient Goals & Concerns
Physiotherapy Goals
Short Term Goals
Long Term Goals
Action
-
+ Add Goal
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
-
2
-
3
-
4
-
5
-
6
-
+ Add Row
Date
Remarks
3 days physio + 2 days cardio(Optional) Rs.9600/- monthly fee
Update
