Ankle Foot Evaluation
Ankle EvaluationName_________________________ DX___________________________________________ Date_________________Current Meds______________________________________________________________________________________PMH_____________________________________________________________________________________________Physician_______________________________Next Appt___________________Onset_______________Initial Evaluation_____ Re-Evaluation_____ Pain Rating_________Funct. Rating__________ Involved: R L SUBJECTIVE: Pain with _____squatting_____walking_____sitting_____running_____stairs____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C/c:_____________________________________________________________________________________________Occupation/Social Hx:_______________________________________________________________________________ Work Duties:______________________________________________________________________________________Pt. Goals:_________________________________________________________________________________________OBJECTIVE:Gait: _____antalgic Trendelenburg R L _____Crutches_____Walker_____Cane_____No AD _____FWB_____PWB_____TTWB_____NWB_____WBAT Other_____________________________________________________________________________________________Observation: (In Standing)WNL R L Knee: ___________________________________________________________________________Effusion:R none min mod severe L none min mod severe Foot:Pes Cavus R L Pes Planus R L Hallux Valgus R L Other____________________________________________________________________________ROM/ Strength: ActivePassiveStrengthR LR LR LDF. _____ P _____ P_____ P _____ P_____ P _____ PPF _____ P _____ P_____ P _____ P_____ P _____ PINV _____ P _____ P_____ P _____ P_____ P _____ PEV _____ P _____ P_____ P _____ P_____ P _____ P1st MTP Ext_____ P _____ P_____ P _____ P_____ P _____ P_____ P _____ PGirth Measurements: (From mid-patella) WNL Bruising Temp. WNL WarmRLAround Malleoli__________Figure 8__________Palpation: ________________________________________________________________________________________Resting BP: ___ / ____ Resting HR: _____Name:_________________________________________ DOB:___________ Flexibility: (NT= normal, T= tight, VT= very tight): __________________________________________________________________________________________________________________________________________________Neurological Screen: Sensation: WNL ↑ ↓ light touch: _______________________________Reflexes: Achilles: WNL ↑ ↓ Other:_________________________________________________________Special Tests: (+ or )RLRLAnterior Drawer__________Eversion Stress Test__________Spring Test__________Inversion Stress Test________________________________Unilateral Stance Time: R ______ Sec. L _______ Sec.Unilat. Heel Raise X 5:RWNL painful weakness/ control Unable to perform LWNL painful weakness/ control Unable to perform 6” step test:RWNL painful weakness/ control Unable to perform LWNL painful weakness/ control Unable to perform Single leg squat:RWNL painful weakness/ control Unable to perform LWNL painful weakness/ control Unable to perform Treatment:__________________________________________________________________________________________________________________________________________________________________________________________ASSESSMENT:_____See Initial Eval Summary/ Plan of Care ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Rehabilitation Potential:Excellent Good Fair PoorSTG/LTG:_____ See Initial Eval Summary/ Plan of CarePLAN:(Circle) # Rx/ wk______~ # wks______ Therex Strengthening Stretching Joint Mobs Moist Heat/ Cold Pack Bracing/ Taping Ultrasound EStim Iontophoresis Proprioception Training Home Program PROM Gait Training ASTYM Manual Therapy Other:___________________________________________________________Avg. Pain Rating _____Self Reported Functional Rating _____Foot Function Index: _____Therapist Signature:_________________________________________Date:_____________ Time: _________ ................
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