THE SARVAJANIK COLLEGE OF PHYSIOTHERAPY, SURATHajee 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)

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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:

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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):

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Range Of Motion: Right Left

Date Joint-- Date

Active Passive Active Passive Active Passive Active Passive

Flexion

Extension

Abduction

Adduction

IR / Supination /InversionER / Pronation /Eversion

Other Joint:

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:

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FIM :-1 – Total AssistancePatient- <25%, Assistant- > 75%2 – Max. AssistancePatient- 25%, Assistant- 75%3 – Moderate AssistancePatient- 50%, Assistant- 50%4 – Minimal AssistancePatient- 75%, Assistant- 25%5 – SupervisionCues without physical contact6 – Modified IndependenceAssistive devices, takes more time7 – Completely Independent

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 Therapist’s Sign

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