FRIENDS PHYSIOTHERAPY AND REHABILTATION CENTRE

DR.NIKHIL CHUGH (P.T) BPT, MPT (SPORTS) M-9671665259 DR.MANJEET KAUR (P.T) BPT, MPT (NEURO) M- 9991117287

TIMINGS: MORNING 9am1pm EVENING 5pm-7pm

DEPARTMENT OF PHYSIO &REHAB

ASSESSMENT FORM

NAME ADDRESS OCCUPATION

AGE/GENDER CONTACT NO. REF.BY

DATE

CHIEF COMPLAINTS:

HOPI:

PAIN HISTORY: LOCATIONONSET-

CHARACTERAGGRAVATING/RELIEVING FACTORSINTENSITY (ON VAS)PAST MEDICAL AND SURGICAL HISTORY: DIABETES MELLITUS HYPERTENSION TUBERCULOSIS SURGERY(IF ANY)

PERSONAL HISTORY: LifestyleSleepObs & Gynae history-

OBSERVATION: Attitude of patientCooperative Obvious swelling YES YES NO NO

Deformity/ContractureLeg length discrepancySkin colorAssistive device usedGait & Posture-

PALPATION: TemperatureTendernessMuscle spasmScar-

EXAMINATION: AROM- Painful PROM- Painful ENDFEELRestricted Restricted Full Full

MANUAL MUSCLE TESTING-

MUSCLE TIGHTNESSWASTINGGIRTHLEG LENGTHPresent Absent

SPECIAL TEST-

NEUROLOGICAL INVOLVEMENT, IF ANY:

YES

NO

SENSORY TESTING: Absent A. superficial B .deep C .cortical Impaired Normal

REFLEXES: Absent Diminished Normal Brisk Clonus

a. superficial b. deep BALANCE AND COORDINATION:

FUNCTIONAL EXAMINATION: ADL Dependent Independent

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

PRECAUTIONS, if any-

PLAN OF TREATMENT:

SHORT TERM GOALS

LONG TERM GOALS

PROTOCOL: