Orthopedic Assessment Form: Sharp Bright Burning Well-Localized Shooting Diffuse Referring Achy

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Orthopedic Assessment Form

Treatment Plan for: _____________________________________________________


Client: __________________________Student: ______________________________
Date: ________________________________________ Consent to assess/treat: Y/N
Interview:
Complaint:____________________________________________________________
Location: _____________________________________________________________
Mechanism of injury: ____________________________________________________
Date of injury: __________________________________________________________
If not trauma-related, how long has the complaint been present? _________________
Pain: □ constant □ intermittent □ referring □ improving □ getting worse □ night □ other
Intensity of Pain 1-10: ____________________________________________________
Character: □ sharp □ bright □ burning □ well-localized □ shooting □ diffuse □ referring □ achy
Neurological Symptoms: _________________________________________________
Aggravating factors: _____________________________________________________
Relieving factors: _______________________________________________________
Occupation: ___________________________________________________________
Hobbies/Sports: ________________________________________________________
Previous diagnosis: _____________________________________________________
Medications: ___________________________________________________________
Previous treatments specific to complaint (massage or other): ____________________
Past history: ___________________________________________________________
Family history related to chief complaint: _____________________________________
Restrictions to activities of daily living: _______________________________________
Other: ________________________________________________________________
Index of Suspicion:
1.
2.
3.
Observation of Posture:

Observation of Gait:

Palpation (Be specific about the areas palpated):


1. Temperature

2. Texture

3. Tenderness

4. Tone:
Range of Motion
Legend
l = some limitation TS=tissue stretch P = mild pain
ll= mod limitation STA=soft tissue approx.
P+ = mod pain
lll= sig. limitation B=bony P++ = severe pain
A=abnormal (describe)W = mild weak
W+ =mod weak
W ++ = severe weak
Joint tested: ___________________________________________________________
Record only those movements that are significant.
Joint Movement Active Free Passive Relaxed Active Resisted

(identify end feel &


state whether
normal
or abnormal)

Is this a capsular pattern of restriction? ______________________________________


If so state the restriction: _________________________________________________
Joints above and below scanned (name the joints and indicate if any
pathology):_____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Neurological Tests
Is neurological testing Indicated? ___________________________________________
Orthopedic Tests
Name the test and state the result and what it indicates. For example, Phalen’s test is
positive for median nerve compression (carpal tunnel syndrome). If there is no specific
test to confirm the condition, state which part of the assessment (and the results) that
does confirm the condition.

To confirm (the first suspicion from the interview):

To differentiate (the second and third suspicions from the interview):

Clinical Impression
1. signs and symptoms (ALL your findings from your assessment must be included
here):

2. location: _________________________________________________________
3. stage of healing: ___________________________________________________
4. condition: ________________________________________________________
5. cause: __________________________________________________________

Short term goals: ______________________________________________________


______________________________________________________________________
Long term goals: _______________________________________________________
______________________________________________________________________
Progression Plan: ______________________________________________________
______________________________________________________________________
Treatment Chart
Client: ________________________________ Therapist: ______________________
Date: _________________________________ Treatment # _____ of _____
Changes from previous treatment: ________________________________________
Special instructions for client: ___________________________________________
Goals Treatment or modality

Hydrotherapy:

Massage:

Remedial Exercise:

Goals Homecare

Hydrotherapy:

Massage:

Remedial Exercise:

Post-treatment observations: ____________________________________________


Therapist signature: ____________________________________________

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