Initial Evaluation and Treatment Plan- Cervicothoracic ...
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Initial Evaluation and Treatment Plan- Lumbosacral/Hip Evaluation
Date of Eval: ____________ Date of Onset:____________
Diagnosis: ________________________________________
History/Mechanism of Injury: _____________________________________________________________
______________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Psychosocial/Functional Deficits: __________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PMH: _________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Current Medications: ____________________________________________________________________
______________________________________________________________________________________
Symptomology: Constant_____ Intermittent_____ Variable_____ Unchanging _____ Daily _____
( or ( symptoms with activities ______________________
( or ( symptoms with positions ______________________
Pain Pattern/Intensity (0-10 scale): Rest______ Activity______
Pain Description:
( AM stiffness that decreases with movement
( Intermittent pain increases as day progresses
( Sharp pain with quick movements
( Numbness/tingling
( Pain that remains unchanged with positions
( Sleep disturbance at night
Comments: _________________________________________
___________________________________________________
___________________________________________________
Observation/Inspection: _______________________________
___________________________________________________
___________________________________________________
Neuro Screen: ( Not Indicated
Knee Ankle Reflexes: _______________ Sensation: __________________________________________
Slump Test/SLRing: ________________
Myotomes: Quads (L3) ____R ____L Tibialis Ant. (L4) ____R ____L EHL (L5) ____R ____L
Gatroc (S1) ____R ____L Hamstrings (S2) ____R ____L Hip Flex (L1-2) ____R ____L
Gait: _________________________________________________________________________________
______________________________________________________________________________________
|Hip +=pain |AROM L |AROM R |PROM L |PROM R |Strength L |Strength R |
|Flexion | | | | | | |
|Extension | | | | | | |
|Abduction | | | | | | |
|Adduction | | | | | | |
|Internal Rot | | | | | | |
|External Rot | | | | | | |
|Lumbar +=pain |AROM |PROM |Resistance |
|Flexion | | | |
|Extension | | | |
|Side Bend R | | | |
|Side Bend L | | | |
|Rotation R | | | |
|Rotation L | | | |
|Rotation L | | | |
|SI March | |SI Compression |Iliac Crest | | |Ischial Tub | | |
|St. FBT | |SI Distraction |ASIS | | |Gr Troch | | |
|Sit FBT | |SI Other |Pubic Ramus | | |ILA | | |
|Leg Length | |SI Other |PSIS | | |Sulcus | | |
Abdominal Strength: _____________________________________________________________________ Palpation: _____________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
Joint Play Assessment: ___________________________________________________________________
Special Tests: __________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________
HEP/Patient Education: __________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________
ASSESSMENT: ________________________________________________________________________
Problems/Physical Findings: ______________________________________________________________
______________________________________________________________________________________
TREATMENT PLAN: __________________________________________________________________
Patient will be seen ______ x/wk for ______ wks or ______ visits for _____________________________
____________________________________________________________________________________________________________________________________________________________________________
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 lumbosacral/hip model as it pertains to the injury? ( Yes ( No _____________
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|Clinician: |
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Place Label Here
Sketch location of pain here
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