THE SARVAJANIK COLLEGE OF PHYSIOTHERAPY, SURAT Hajee A.M. Lockhat & Dr. A.M.

Mulla Sarvajanik Hospital, Surat MUSCULOSKELETAL PHYSICAL THERAPY ASSESSMENT

Name: _______________________________________________ Age/Sex: __________ Occupation: _____________________

Date: ________________ OPD No.: ____________ Ref Dept.: ____________ Handedness: __________

Address: _____________________________________________ _____________________________________________________

Contact No.: __________________________________________________________________ Height (cm): _________ Weight (kg): _______________ BMI (kg/m2): ________

Medical Diagnosis (if any): ______________________________________________________ Special Precautions (if any): ____________________________________________________ Chief Complaint:

Present H/O:

Pain H/O:

Intensity (NRS): ---------------------------------------------------------------------(No pain) 0 1 2 3 4 5 6 7 8 9 10 (Maximum)

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Onset: Duration: Quality: Rhythm: Prick / Dull ache / Burning / Throbbing / Pulling / Sharp shooting Constant / Intermittent

Manner Of Expressing Pain: Verbal / Facial expression Aggravating Factors: Releiving Factors: Effects Of Pain On Physical Activity: Getting in/out of bed, Getting in/out of chair, Standing/Walking, Walking up/down stairs, Work activities, Other activities (sitting, cooking, dressing, cleaning, lifting, etc.) Accompanying symptoms: Appetite: Sleep: Irritability:

Medical / Surgical / Occupational H/O :

Personal History: a. Smoking: b. Tobacco chewing: c. Alcohol consumption: d. Physical / Recreational activity: Yes / No Since:_____________ Yes / No Since:_____________ Yes / No Since:_____________

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Family History:

Socio-economic Status: Investigation:

Poor / Fair / Good

Vital Signs: Heart Rate: Blood Pressure: /min / mmHg Respiratory Rate: Temperature: /min

General Examination:
General Body Built: Posture: Gait:

Local Examination:
Temperature: Swelling: ______________________________ Soft / Firm / Hard Tenderness: Pitting / Nonpitting

Spasm:

Crepitus:

Attitude of the limbs / body part:

Any other findings:(e.g.,Trophical changes / Scar / Wound):

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Range Of Motion: Right Date Joint--

Left Date

Active Passive Active Passive Flexion Extension Abduction Adduction IR / Supination / Inversion ER / Pronation / Eversion Other Joint:

Active

Passive

Active

Passive

Tightness / Contracture / Deformity:

Girth Measurement:

Muscle Power:

Limb Length Measurement:

Functional Evaluation: Upper Limb: Dressing: Combing: Washing: Eating: Perineal and back hygiene: Other: Lower Limb: Walking: Stair Climbing: Squatting: Crossed Leg Sitting: Cycling: Other: Gait Analysis:

FIM :1 Total Assistance Patient- <25%, Assistant- > 75% 2 Max. Assistance Patient- 25%, Assistant- 75% 3 Moderate Assistance Patient- 50%, Assistant- 50% 4 Minimal Assistance Patient- 75%, Assistant- 25% 5 Supervision Cues without physical contact 6 Modified Independence Assistive devices, takes more time 7 Completely Independent

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Special Tests:

Other System Examination: Cardiovascular / Pulmonary System:

Neuromuscular System:

Any Other System:

PROBLEM LIST:

PFD (Physical & Functional Diagnosis):

PHYSIOTHERAPY MANAGEMENT AIMS: -Short Term:

-Long Term:

TREATMENT PLAN:

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HOME PROGRAM:

ERGONOMIC ADVICES:

Prognosis:

Physical Therapists Sign

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