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Initial Evaluation and Treatment Plan- Lumbosacral/Hip Evaluation

Date of Eval: ____________ Date of Onset:____________
Place Label Here Diagnosis: ________________________________________

History/Mechanism of Injury: _____________________________________________________________

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Psychosocial/Functional Deficits: __________________________________________________________
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PMH: _________________________________________________________________________________
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Current Medications: ____________________________________________________________________
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Symptomology: Constant_____ Intermittent_____ Variable_____ Unchanging _____ Daily _____
 or  symptoms with activities ______________________
 or  symptoms with positions ______________________
Pain Pattern/Intensity (0-10 scale): Rest______ Activity______
Pain Description:
 AM stiffness that decreases with movement
 Intermittent pain increases as day progresses
 Sharp pain with quick movements
 Numbness/tingling Sketch location of pain here
 Pain that remains unchanged with positions
 Sleep disturbance at night
Comments: _________________________________________
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Observation/Inspection: _______________________________
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Neuro Screen:  Not Indicated
Knee Ankle Reflexes: _______________ Sensation: __________________________________________
Slump Test/SLRing: ________________
Myotomes: Quads (L3) ____R ____L Tibialis Ant. (L4) ____R ____L EHL (L5) ____R ____L
Gatroc (S1) ____R ____L Hamstrings (S2) ____R ____L Hip Flex (L1-2) ____R ____L
Gait: _________________________________________________________________________________
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Hip +=pain AROM L AROM R PROM L PROM R Strength L Strength R

Flexion
Extension
Abduction
Adduction
Internal Rot
External Rot
Lumbar +=pain AROM PROM Resistance
Flexion
Extension
Side Bend R
Side Bend L
Rotation R
Rotation L
Rotation L
SI March SI Compression Iliac Crest Ischial Tub
St. FBT SI Distraction ASIS Gr Troch
Sit FBT SI Other Pubic Ramus ILA
Leg Length SI Other PSIS Sulcus
Abdominal Strength: _____________________________________________________________________
Palpation: _____________________________________________________________________________
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Joint Play Assessment: ___________________________________________________________________
Special Tests: __________________________________________________________________________
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HEP/Patient Education: __________________________________________________________________
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ASSESSMENT: ________________________________________________________________________
Problems/Physical Findings: ______________________________________________________________
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TREATMENT PLAN: __________________________________________________________________
Patient will be seen ______ x/wk for ______ wks or ______ visits for _____________________________
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GOALS BY

Barriers to achieving treatment goals?  Yes  No ___________________________________________

Family/patient involved in and verbalized understanding of goals?  Yes  No ____________________
Patient was instructed in lumbosacral/hip model as it pertains to the injury?  Yes  No _____________

Clinician: