ASSESSMENT PERFORMA

Date of assessment: __________

Name:
Age:
Gender:
Address:
Occupation:
Marital Status:
Socio-Economic Status:
Dominance:
Referral:

Presenting Complaints:

History of Present Illness:

 Onset:

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 Mechanism of Injury:

 Location: __________________________
 Radiation: ______
 Duration and Frequency:
_______________
 Aggravating factors:

 Relieving Factors:

 Pain - Constant / Episodic / Periodic / Occasional

 Quality of Pain:______________________________________________________
 Diurnal Variation:

 Intensity Of Pain:-

 Locking of joint/Giving way/Instability:

__________________________
 Behavior of symptoms/ relation with activity:

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 48 hour pattern:
 Specific Medical History:

 Abnormal sensation:
 Associated problems ( if any):
Past Medical History:
 DM/ HT/ TB/ Allergy
 Treatment History/Surgical History:

 Family History:

 Obstetric/ Gynecological History:

 Personal history:

 Social History:
 Occupational history:

 Recreational history:

 Functional limitation:

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 OBSERVATION
GENERAL OBSERVATION
 Mental and Emotional state:

 Posture:

 Gait:

____________________
 Assistive Device:
_______________
 Willingness To Participate:

LOCAL OBSERVATION
 Attitude of limb: __________
 Bony Contours & alignment/Obvious Deformity :
_______________________________________________
 Soft Tissue Contours: __________
 Swelling : _____________________
 Muscle bulk: ______
 Color & texture of skin: ____________________
 Trophic changes in skin & nails (if any):
____________________________________________________
 Bursitis or callosities:
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 Involuntary movement:
 Scar/ Sinuses:

EXAMINATION:

 Vitals examination:

 Mental status examination:

 Local examination:
a) Tenderness:
b) Swelling:
c) Difference in tissue texture:
d) Scar examination: -Tenderness/ Adherence/ Vascularity

e) Fasciculation:
f) Peripheral Pulses:
g) Crepitation:
h) Temperature:
 Sensory examination:

Sensations Upper Extremity Comments

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 Right Left

Pain

Temperature

Touch

Vibration

Two – Point Disc

Kinesthesia

Proprioception

Stereognosis

Sensations Lower Extremity Comments

Right Left

Pain

Temperature

Touch

Vibration

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Two – Point Disc

Kinesthesia

Proprioception

Sensations Trunk Comments

Right Left

Pain

Temperature

Touch

Vibration

Two – Point Disc

 Motor examination:-
a) Tone:

__________
b) Active Range Of Motion:-

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 Joint ROM Notes

c) Passive Range Of Motion:-

Joint ROM END FEEL Notes

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Capsular Pattern: ____________
_______
d) Resisted isometric contraction: __
__
______________________
e) M.M.T:-
JOINT MUSCLE GRADE

GROUP LEFT RIGHT

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f) Muscle Length Testing:

____________________
g) Joint play:

_______________
h) Coordination: __________
i) Measurement:-
 LLD – True: ___________
- Apparent: ______
 Limb Girth: ___________

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  Chest expansion: ___________
 Scar measurement: ________________
j) Functional assessment:

________________
k) Special tests:

____________________
l) Balance :

_______________
m) Gait :

____________________
 Investigations:

_______________________________
 Differential diagnosis:

____________________
 Provisional diagnosis:

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 _____________________
 Goals of Treatment:

__________________________

 Treatment plan:

_________________________
 Follow up:

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