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    Musculoskeletal Physical Therapy Assessment

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    lecturio
    The document appears to be a physical therapy assessment form from the Sarvajanik College of Physiotherapy in Surat, India. It collects information about a patient's medical history, symptoms, functional status, physical examination findings, and establishes problems and treatment goals. The assessment will be used to inform the patient's physical therapy management plan.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Musculoskeletal Physical Therapy Assessment

    Uploaded by

    lecturio
    993 views6 pages
    The document appears to be a physical therapy assessment form from the Sarvajanik College of Physiotherapy in Surat, India. It collects information about a patient's medical history, symptoms, functional status, physical examination findings, and establishes problems and treatment goals. The assessment will be used to inform the patient's physical therapy management plan.

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    Original Title

    125315653-Musculoskeletal-Assessment-Format-SCOP

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    The document appears to be a physical therapy assessment form from the Sarvajanik College of Physiotherapy in Surat, India. It collects information about a patient's medical history, symptoms, functional status, physical examination findings, and establishes problems and treatment goals. The assessment will be used to inform the patient's physical therapy management plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    993 views6 pages

    Musculoskeletal Physical Therapy Assessment

    Uploaded by

    lecturio
    The document appears to be a physical therapy assessment form from the Sarvajanik College of Physiotherapy in Surat, India. It collects information about a patient's medical history, symptoms, functional status, physical examination findings, and establishes problems and treatment goals. The assessment will be used to inform the patient's physical therapy management plan.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 6

    THE SARVAJANIK COLLEGE OF PHYSIOTHERAPY, SURAT

    Hajee A.M. Lockhat & Dr. A.M. Mulla Sarvajanik Hospital, Surat
    MUSCULOSKELETAL PHYSICAL THERAPY ASSESSMENT

    Name: _______________________________________________ Date: ________________

    Age/Sex: __________ Occupation: _____________________ OPD No.: ____________

    Address: _____________________________________________ Ref Dept.: ____________

    _____________________________________________________ Handedness: __________

    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)

    Page 1 of 6
    Onset:

    Duration:

    Quality: Prick / Dull ache / Burning / Throbbing / Pulling / Sharp shooting

    Rhythm: 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: Sleep:


    Appetite: Irritability:

    Medical / Surgical / Occupational H/O :

    Personal History:

    a. Smoking: Yes / No Since:_____________

    b. Tobacco chewing: Yes / No Since:_____________

    c. Alcohol consumption: Yes / No Since:_____________

    d. Physical / Recreational activity:

    Page 2 of 6
    Family History:

    Socio-economic Status: Poor / Fair / Good

    Investigation:

    Vital Signs:

    Heart Rate: /min Respiratory Rate: /min


    .
    Blood Pressure: / mmHg Temperature: C

    General Examination:

    General Body Built:

    Posture:

    Gait:

    Local Examination:

    Temperature:

    Swelling: ______________________________ Soft / Firm / Hard Pitting / Nonpitting

    Tenderness:

    Spasm:

    Crepitus:

    Attitude of the limbs / body part:

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

    Page 3 of 6
    Range Of Motion:
    Right Left
    Date Joint-- Date

    Active Passive Active Passive Active Passive Active Passive


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

    Tightness / Contracture / Deformity:

    Girth Measurement:

    Muscle Power:

    Limb Length Measurement:

    Functional Evaluation: FIM :-


    Upper Limb: 1 – Total Assistance
    Dressing: Patient- <25%, Assistant- > 75%
    Combing: 2 – Max. Assistance
    Washing: Patient- 25%, Assistant- 75%
    Eating: 3 – Moderate Assistance
    Perineal and back hygiene: Patient- 50%, Assistant- 50%
    Other: 4 – Minimal Assistance
    Patient- 75%, Assistant- 25%
    Lower Limb: 5 – Supervision
    Walking: Cues without physical contact
    Stair Climbing: 6 – Modified Independence
    Squatting: Assistive devices, takes more time
    Crossed Leg Sitting: 7 – Completely Independent
    Cycling:
    Other:
    Gait Analysis:

    Page 4 of 6
    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:

    Page 5 of 6
    HOME PROGRAM:

    ERGONOMIC ADVICES:

    Prognosis:

    Physical Therapist’s Sign

    Page 6 of 6

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