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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
Address
Koodal pudur
Occupation Type *
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Government
Non-Government
Senior Citizen
Others
Designation
Nature of Work
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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
4+ yrs - Neck pain gradual onset - associated pain in Right shoulder-arm-TMJ
Onset
Sudden
Insidious
Gradual
Treatment Taken
Dr Chinnadurai, Ortho Dr Ram, Neuro - Preethi hospitals Dr Bharathi Meenakshi sundaram, SMS hospital Dr Prakash, MDS and Maruthi hospital - Psychiatric counselling AVN, Vilachery
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Blue Physiotherapy - Exercises
Update
Present Complaints
Neck pain - ADL - Inactive in ADL - Associated pain in sitting too Pain - Travel - deep sleep - sometimes unpredictable Pain - associated to TMJ - Right shoulder -arm - headache - Nausea
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
25-27-29
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
Right Upper trap
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
Had so many treatments, but not recovered. Had some relief with our one week treatment a year ago. FOCUS: Spinal mobility - Upper trap stretch - Strength scapula retractors and shoulder external rotators Weight loss - Build muscular Endurance - Periodical counselling - No Gym experience
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
-
3 sessions
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Corrective Exercises
S.No
Exercise
Sets
Reps
Time
Date
Remarks
Action
1
Start with Neck ROM and progress to Passive neck stretches and Neural mobilizations
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Date
Remarks
Pain relief with weight loss - Fee paid Rs.11000/- for first month From second month Rs.8500 per month Review after every 3 PT (Strength training) sessions
Update