Initial Evaluation and Treatment Plan- Cervicothoracic ...
Place your header here
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:______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
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
[pic]
Sketch location of pain here
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