Initial Evaluation and Treatment Plan- Cervicothoracic Evaluation - Download as DOC by 93l430Nn

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                 Initial Evaluation and Treatment Plan- Knee 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 _______________________
Pain Pattern/Intensity (0-10 scale): Rest______ Activity______
Comments: __________________________________________
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Observation/Inspection: ________________________________
____________________________________________________             Sketch location of pain here
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Q Angle:     Left______       Right______
Gait: _______________________________________________
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Assistive Device:  None  Cane  Crutches  Walker
WB Status:  None  FWB  WBAT  PWB Amt:_____

Knee +=pain      AROM L          AROM R        PROM L        PROM R          Strength L   Strength R
Flexion
Extension

    Strength L          Muscle         Strength R        Right          Special Tests      Left
5    4 3 2 1                       5    4 3 2 1                           Valgus
5    4 3 2 1                       5    4 3 2 1                            Varus
5    4 3 2 1                       5    4 3 2 1                          Mc Murray
5    4 3 2 1                       5    4 3 2 1                           Apley’s
5    4 3 2 1                       5    4 3 2 1                          Lachman
5    4 3 2 1                       5    4 3 2 1                         Ant. Drawer
5    4 3 2 1                       5    4 3 2 1                         Post. Drawer
5    4 3 2 1                       5    4 3 2 1
5    4 3 2 1                       5    4 3 2 1
Palpation: _____________________________________________________________________________
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Patella Mobility:  Normal            Hyper        Hypo Comments:__________________________
      Left            Flexibility        Right            Left              Girth          Right
                                                                            15cm
                                                                             5cm
                                                                          Joint Line
                                                                            15cm
HEP/Patient Education: __________________________________________________________________
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ASSESSMENT: ________________________________________________________________________
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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 knee as it pertains to the injury?  Yes  No ____________________________


Clinician:

								
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