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Pts Name:
Gender:
Citizenship:
Handedness:
Date of Admission:
Date of Referral:
Dx:
Age:
Civil Status:
Occupation:
Referring Dr:
Referring Unit:
Date of I. E.:
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___ DM
___ HPN
___ Cardiovascular
___ Chest / Respiratory
___ Allergies
___ Others
___ DM (P / M)
___ HPN (P / M)
___ Cardiovascular (P / M)
___ Chest / Respiratory (P / M)
___ Sedentary
___ Alcoholic
___ Non-smoker
___ Active
___ Athletic
___ Type A
___Type B
___ Beverage
___ Smoker (packs / yr. = # of packs/day x # of yrs. Smoking)
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BP: ________
O2 SAT _____
PR: _____
RR: _____
TEMP: ____
___ Ambulatory
___ Ectomorph
___ Alert
___ Swelling
___ Attachments
___ W/C
___ Mesomorph
___ Coherent
___ Skin Color
___ Scar / Ulcers
cc
___ (m) tone
___Subluxation
___Tenderness
___ (m) spasm/guarding
___Edema
___Nodules
STDs used (pin-pain; cotton-light touch; thumb-pressure)
Grading: 2 = Intact (100%)
1 = Impaired (1 99%)
0 = Absent
FINDINGS: _______________________________________________________________
SIG: ____________________________________________________________________
___ atonic
___ hypotonic
___ normotonic
___ hypertonic
FINDINGS: _______________________________________________________________
SIG: ____________________________________________________________________
DTR
O areflexia
+ - hyporeflexia
++ - normoreflexia
+++ - hyperreflexia
FINDINGS: _______________________________________________________________
SIG: ____________________________________________________________________
Joint ROM
PROM
RIGHT
AROM
LEFT
RIGHT
LEFT
Joint ROM
PROM
RIGHT
nd
AROM
LEFT
RIGHT
LEFT
th
2 5 MTP Flexion 0 40
Extension 0 40
nd
2 5th PIP Flexion 0 35
2nd 5th DIP Flexion 0 60
Cervical Flexion 0 45
Extension 0 45
Lat. Flexion 0 45
Rotation 0 60
FINDINGS: _____________________________________________________________________
SIG: __________________________________________________________________________
5 = Normal
4 = Good
C5 Elbow Flexors
C6 Wrist Extensors
C7 Elbow extensors
C8 Finger Flexors of 3rd DIP
T1 Small Finger Abductors
L2 Hip Flexors
L3 Knee Extensors
L4 Ankle Dorsiflexors
L5 Long Toe Extensors
S1 Ankle Plantarflexors
3 = Fair
5
5
5
5
5
5
5
5
5
5
4
4
4
4
4
4
4
4
4
4
2 = Poor
RIGHT
3 2
3 2
3 2
3 2
3 2
3 2
3 2
3 2
3 2
3 2
1
1
1
1
1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
1 = Trace
5
5
5
5
5
5
5
5
5
5
LEFT
4 3
4 3
4 3
4 3
4 3
4 3
4 3
4 3
4 3
4 3
0 = Absent
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
FINDINGS: _____________________________________________________________________
SIG: __________________________________________________________________________
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PHYSIOTHERAPIST: ________________________________
ID #: _______________________
SIGNATURE: _____________________________________
DATE: ______________________