Shoulder Evaluation Form - RehabEdge
Shoulder EvaluationName_________________________ DX_____________________________________________ Date:_____________Current Meds______________________________________________________________________________________PMH_____________________________________________________________________________________________Physician_______________________________Next Appt___________________Onset_______________Initial Evaluation:_____ Re-Evaluation:_____ Pain Rating_________Funct. Rating__________Involved: R LDominant: R L SUBJECTIVE: Radiating pain R L ______________________Numbness/ Tingling R L ____________________ Trouble sleeping _____# Hours/ night_____ Symptoms worse in A.M. P.M. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C/c:_____________________________________________________________________________________________Occupation/Social Hx:_______________________________________________________________________________ Work Duties:______________________________________________________________________________________Pt. Goals:_________________________________________________________________________________________OBJECTIVE:Observation:_____Rounded shoulders_____Forward head Thoracic Kyphosis Lumbar lordosis Scapular Winging R L With Repeated Shoulder Flex: R LOther_________________________________________________________________________________ADLs:_____Tuck in shirt/Bra_____Fix hair_____Dressing_____Bathing_____CleaningOther_________________________________________________________________________________ROM/ Strength: Active PassiveStrengthR LR LR LShoulder Flex _____ P _____ P_____ P _____ P_____ P _____ PShoulder Ext _____ P _____ P_____ P _____ P_____ P _____ PShoulder ABD _____ P _____ P_____ P _____ P_____ P _____ PShoulder IR _____ P _____ P_____ P _____ P_____ P _____ PShoulder ER _____ P _____ P_____ P _____ P_____ P _____ PCervical AROM: WNL ____________________________________________________________________Joint Mobility:_____________________________________________________________________________Palpation: _________________________________________________________________________________________________________________________________________________________________________________________Name:_______________________________________ Date:____________________ Flexibility: (NT = not tight, T = tight, VT = very tight): ________________________________________________________________________________________________________________________________________________________Neurological Screen:Sensation:_____WNLOther_____________________________________________________Reflexes:Biceps R_____L_____Triceps R_____L_____Brachioradialis R_____L_____Resting BP: ___ / ____ Resting HR: _____Special Tests:(Circle)RL RLImpingement (end range)+ P+ P Hand to Neck____ (0 - 4)____Impingement (#2)+ P+ P Hand to Scapula____ (0 - 4)____Apprehension+ P+ P Hand to opposite scapula____ (0 - 3)____Relocation+ P+ PSpeed’s+ P+ PEmpty Can+ P+ PNeural Tension (median)+ Bias: Passive Active+ Bias:Passive ActiveNeural Tension (ulnar)+ Bias: Passive Active+ Bias:Passive ActiveTreatment:________________________________________________________________________________________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 ASTYM Home Program Scapular Stab. PROM Manual Therapy Other:___________________________________________________________Avg. Pain Rating _____Self Reported Functional Rating _____SPADI: _____Therapist Signature:_________________________________________Date:__________ Time:___________ ................
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