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c

    
Pts Name:
Gender:
Citizenship:
Handedness:
Date of Admission:
Date of Referral:
Dx:

Age:
Civil Status:
Occupation:
Referring Dr:
Referring Unit:
Date of I. E.:

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c 
___ DM
___ HPN

___ Cardiovascular
___ Chest / Respiratory

___ Allergies
___ Others

___ DM (P / M)
___ HPN (P / M)

___ Cardiovascular (P / M)
___ Chest / Respiratory (P / M)

___ Sedentary
___ Alcoholic
___ Non-smoker

___ Active
___ Athletic
___ Type A
___Type B
___ Beverage
___ Smoker (packs / yr. = # of packs/day x # of yrs. Smoking)

 

 

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BP: ________
O2 SAT _____

PR: _____
RR: _____

TEMP: ____


___ Ambulatory
___ Ectomorph
___ Alert
___ Swelling
___ Attachments

___ W/C
___ Mesomorph
___ Coherent
___ Skin Color
___ Scar / Ulcers

___ Assistice device:

___ Endomorph
___ Cooperative
___ Deformities

cc
___ (m) tone
___Subluxation

___Tenderness
___ (m) spasm/guarding

___Edema
___Nodules


 
 
 STDs used (pin-pain; cotton-light touch; thumb-pressure)
Grading: 2 = Intact (100%)
1 = Impaired (1 99%)
0 = Absent

FINDINGS: _______________________________________________________________
SIG: ____________________________________________________________________
 
___ atonic

___ hypotonic

___ normotonic

___ hypertonic

FINDINGS: _______________________________________________________________
SIG: ____________________________________________________________________
 
 
DTR
O areflexia
+ - hyporeflexia
++ - normoreflexia
+++ - hyperreflexia

FINDINGS: _______________________________________________________________
SIG: ____________________________________________________________________


Joint ROM

PROM
RIGHT

Shldr Flexion 0 180

Hyperextension 0 - 60
Abduction 0 180
Adduction 180 0
Ext. Rotation 0 90
Int. Rotation 70 0
Elbow Flexion 0 150
FA Pronation 0 80
Supination 0 80
Wrist Flexion 0 80
Extension 0 70
Ulnarl Dev. 0 30
Radial Dev. 0 20
Thumb CMC Flexion 0 15
Extension 0 20
Abduction 0 70
Thumb MCP Flexion 0 50
Thumb IP Flexion 0 80
2nd 5th MCP Flexion 0 90
Hyperextension 0 45
2nd 5th PIP Flexion 0 100
2nd 5th DIP Flexion 0 90
Hyperextension 0 10
Hip Flexion 0 120
Extension 0 - 30
Abduction 0 45
Adduction 0 30
Ext. Rotation 0 45
Int. Rotation 0 45
Knee Flexion 0 135
Ankle Dorsiflexion 0 20
Plantarflexion 0 50
Foot Inversion 0 35
Eversion 0 15
Subtalar Inversion 0 5
Eversion 0 5
Transverse Inversion 0 20
Eversion 0 - 10
1st MTP Flexion 0 45
Extension 0 70
1st IP Flexion 0 90

AROM
LEFT

RIGHT

LEFT

Joint ROM

PROM
RIGHT

nd

AROM
LEFT

RIGHT

LEFT

th

2 5 MTP Flexion 0 40
Extension 0 40
nd
2 5th PIP Flexion 0 35
2nd 5th DIP Flexion 0 60
Cervical Flexion 0 45
Extension 0 45
Lat. Flexion 0 45
Rotation 0 60
FINDINGS: _____________________________________________________________________
SIG: __________________________________________________________________________

5 = Normal

4 = Good

C5 Elbow Flexors
C6 Wrist Extensors
C7 Elbow extensors
C8 Finger Flexors of 3rd DIP
T1 Small Finger Abductors
L2 Hip Flexors
L3 Knee Extensors
L4 Ankle Dorsiflexors
L5 Long Toe Extensors
S1 Ankle Plantarflexors

3 = Fair

5
5
5
5
5
5
5
5
5
5

4
4
4
4
4
4
4
4
4
4

2 = Poor
RIGHT
3 2
3 2
3 2
3 2
3 2
3 2
3 2
3 2
3 2
3 2

1
1
1
1
1
1
1
1
1
1

0
0
0
0
0
0
0
0
0
0

1 = Trace

5
5
5
5
5
5
5
5
5
5

LEFT
4 3
4 3
4 3
4 3
4 3
4 3
4 3
4 3
4 3
4 3

0 = Absent

2
2
2
2
2
2
2
2
2
2

1
1
1
1
1
1
1
1
1
1

0
0
0
0
0
0
0
0
0
0

FINDINGS: _____________________________________________________________________
SIG: __________________________________________________________________________
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PHYSIOTHERAPIST: ________________________________

ID #: _______________________

SIGNATURE: _____________________________________

DATE: ______________________