DEPARTMENT OF PHYSIOTHERAPY

Date:

C/S/B:

Assessinent Form
. Nam
2. Age/Oender:
3. Address:
4. Phone No.
S. Occupation:
6. Refered By
7. Hand Domiinence:
8 Chief Complaints:
SubjectiveAssessment
A. Present History:
. Onset:
2 Mechanism oi Injury:
Progress of Symptoms: Improved/ Same/ Worsen
4 Treatment Received &Effects
5. Intenasity:

AUT KURT EvEN.AAORE WHOLEtor

unEpr TLEORO ENER:A*OR

Area
A.rea:
Paraesthesial Anaesthesia:
Nature/Quality:
Morniig Pain:
Night' Pair:
24- hour Variat:on:
Past History:
Medical/Surgical Aistory:
D. Medicátions:
E. Fainily History
F. Social/Personal History:
G. Aggravating Factors:
Relievirg ('actors:
Ancilla1 y Procedures
Objective Assessment
Posture:
PPA:
Gait:
3. On Arival
Deformity:
Body Built:
Altachment
Swelling:
4. Anthropometric Measurements:

LLD:
Swelling:
Skin fold:

Amputation:
5. Selective Tissue Tension Test
of Movement
Active Moverent: Quality
ii. Passive Movement:

End Feel:
Capsular Fattern:
Joint Sounds: Crepitus/Clicks/Snapping/Cracks

Joiut Play: Grade........

ii. Resisted Isometric Movement: Painless/Wcak& Painful
& Painful/Weak&&
Strang & Painless/Strong
5. Muscle Perforimance Test;
Strength
Power
Endurance:
Agility:
7 Neurornusular Examination:
Dermatome:
Myotome:
Reflexes:
Limb fension Test:
ULTT & Lower
8. Range of Motion:
Active:
Passive:
9. Special Tests:

10. Functional Assessment:

11. Palpation:
i. Swelling:
Boney (Osteophyte)
Boggy (Symovial)
Soft (Fluid)
(Blood)
Thick and Warm
Warm (Puss)
Thick, Non fluctuating &
(Callus)
Tough, Dry & Leathery
Thick with indentation
(Oedema)
ii. Variation in Temperature
ii. Muscle Spasm:
iv. Abnorma Sensation:

12. Diagnosis:
13. Treatment: