Physical Therapy Assessment Chart
Patient ID :
Name :
Age & Sex :
Address :
Occupation :
Life Style : Non Smoker: Smoke /Day
No Alcoholic: Alcohol /Day
No Exercise: Exercise /Day
Past medical history :
Present medical history :
Surgical history :
Medications :
Family history :
Lab investigations : Hb :
ESR :
Blood sugar (F) :
Blood sugar (PP) :
Rheumatoid Factor :
Pain Assessment :
Area of Pain :
Nature of Pain :
Chronology of Pain :
Aggravating Factors :
Relieving Factors :
Visual Analog Scale :
0 1 2 3 4 5 6 7 8 9 10
Range of Motion :
AROM : Flexors :
Extensors :
PROM : Flexors :
Extensors :
Swelling :
End-Feel:
Muscle Power:
Sensory Assessment:
Superficial Sensations:
Deep Sensations :
Deep Tendon Reflexes :
Special Tests :
Provisional Diagnosis :
Follow Up:
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