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: _____________________________________________________________

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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 ______________________

( 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: _________________________________________

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Observation/Inspection: _______________________________

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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: _________________________________________________________________________________

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|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: _____________________________________________________________________________

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Joint Play Assessment: ___________________________________________________________________

Special Tests: __________________________________________________________________________

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HEP/Patient Education: __________________________________________________________________

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ASSESSMENT: ________________________________________________________________________

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 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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