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Patient Assessment - Page 1 (Edit)
Date *
Patient Name *
PR No
Age / Gender *
F
M
T
Contact No
Reference
Address
Dindugal
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
severe neck pain . from 27 th january . 10 kg bag . in railway platform 45 steps running in 8 mins to catch trrain . before 3 yrs conslut ortho , treated . diificult in daily activites . cant prolng sitting . forward neck . 09.03.2026 :: pain started on the left side of the neck .
Onset
Sudden
Insidious
Gradual
Treatment Taken
Investigation Details
Not Taken
Done , Not Produced
Attached with Case Sheet
Current Physiotherapy Episode
1
2
>3
Previous Session Details
Update
Present Complaints
trapezius , pain , upper chest pain . pain during cough , radiating pain on right arm , pain on armas and forearm , necxk flexion pain on c7 , both side flexion neck stretch on other side with pain , both upper limb tension test pain on neck ,right occipital pain , neck stiffness. pain right upper pectoral . ______________________________________________________________________________________________________________________________________________________________________________ Severe Neck Pain with referring to Right Posterior Arm. Nocturnal Pain. complete rest , collar on neck . Occupation Railway Guard carrying backpack arround 10 kg . consulted and treated with ortho in Dindugal.
Symptoms
Constant
Intermittent
Worsening Factors
Relieving Factors
Pain Chart Notes
26 , 28 09.03.2026 : referring pain on right side settle down 26,28 settle down. 3 left side pain
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
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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
-
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End Feel
Soft
Firm
Hard
Empty
MMT
-
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Special Tests
Special Test 1
Special Test 2
Remarks
ROM Cervical Spine decreased in all Anterior and Posterior . Upper Limb Tension Test (ULTT) Bilateral
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
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Details
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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
-
2
-
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Date
Remarks
09/03/2026 : Pain is better on the right side of the neck . referrring pain to the Upper Limb got settled . pain started on the left side of the neck .
Update
