Initial Evaluation and Treatment Plan- Cervicothoracic ...



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Initial Evaluation and Treatment Plan- Ankle/Foot Evaluation

Date of Eval: ____________ Date of Onset:____________

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: ________________________________ Can draw body area here ____________________________________________________

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Gait: ________________________________________________

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Proprioception/Somatosensory: __________________________

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|+ = pain |AROM L |AROM R |PROM L |PROM R |Strength L |Strength R |

|Ankle DF | | | | | | |

|Ankle PF | | | | | | |

|Ankle INV | | | | | | |

|Ankle EVER | | | | | | |

|Great Toe Flex | | | | | | |

|Great Toe Ext | | | | | | |

|Toe II-V Flex | | | | | | |

|Toe II-V Ext | | | | | | |

Palpation:______________________________________________________________________________

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Joint Play Assessment: ___________________________________________________________________

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Special Tests: __________________________________________________________________________

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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

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Barriers to achieving treatment goals? ( Yes ( No ___________________________________________

Family/patient involved in and verbalized understanding of goals? ( Yes ( No ____________________

Patient was instructed in ankle/foot model as it pertains to the injury? ( Yes ( No __________________

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|Clinician: |

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Place Label Here

L R R L R L

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Sketch location of pain here

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