R.V.

COLLEGE OF PHYSIOTHERAPY

NO.CA 2/83-3, 9TH MAIN RD, 4TH BLOCK, JAYANAGAR, BENGALURU, KARNATAKA
560011

EMAIL: RVBPT@YAHOO.CO PHONE: 080-26632888

ORTHOPAEDIC ASSESSMENT CHART

DEMOGRAPHIC DETAILS:

NAME: OP NO. REFERRED BY:

AGE/SEX: DATE: ASSESSED BY:

OCCUPATION: DIAGNOSIS: SUPERVISED BY:

ADDRESS/PHONE:

CHIEF COMPLAINTS(WITH DURATION AND ADL AFFECTED):

HISTORY OF PRESENT ILLINESS:

PAST MEDICAL HISTORY:

PERSONAL HISTORY:

FAMILY HISTORY:

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ON OBSERVATION:

GENERAL:

 AREA AFFECTED:
 BUILT OF THE PATIENT:

POSTURE:

LOCAL:

 SWELLING:
 REDNESS:
 WOUND:
 TROPIC CHANGES:
 SCARS:
 MUSCLE WASTING:
 DEFORMITIES:

ON EXAMINATION/PALPATION:

 TENDERNESS:
 MUSCLE SPASM:
 WARMTH
 CREPITUS
 EDEMA:. PITTING:. NON PITTING:
 PULSE:. CAPPILARY FILLING/ BLANCHING

PAIN ASSESSMENT:

 ONSET:

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  PALLIATIVE AND PROVOCATIVE CONCERN:
 QUALITY OF PAIN: BURNING THROBBING DULL SHOTTING
 RADIATING: YES NO
 SEVERITY OF PAIN:
 TIME, DURATION OF PAIN:

MUSCLE POWER(MMT):

MUSCLE RIGHT LEFT

RANGE OF MOTION(ROM):

JOINT MOTION RIGHT LEFT

ACTIVE PASSIVE ACTIVE PASSIVE

ACCESSORY GLIDES/JOINT PLAY: RESTRICTED ROM:

MUSCLE LENGTH MEASUREMENTS:

TIGHTNESS
CONTRACTURE

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SEGMENTAL GIRTH AND LENGTH MEASUREMENTS:
TRUE LENGTH APPARENT
LENGTH

SENSORY EVALUATION:

 TOUCH

 TEMPERATURE

 PRESSURE

 PROPRIOCEPTION

SELECTIVE TENSION PROCEDURE/SPECIAL TEST/ PROVOCATIVE TEST:

GAIT ANALYSIS:

INVESTIGATION:

 XRAY
 CT SCAN/MRI
 LAB TESTS
 PROCEDURES DONE

DIFFERENTIAL DIAGNOSIS:

PT DIAGNOSIS/ FUNCTIONAL DIAGNOSIS:

IMPAIRMENT IDENTIFIED/DISABILITY/HANDICAPPED:

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PROBLEMS LIST:

PT AIMS:

PT TREATMENT PLANS:

SHORT TERM

LONG TERM

HOME PROGRAMS:

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PROGNOSIS/FOLLOW UP:

INTERN: CLINICAL SUPERVISOR

SKILL DEVELOPMENT(SPECIFY THE SKILL YOU DEVELOPED):

LIMITATIONS IN SKILL DEVELOPMENT:

DISCUSSION WITH STAFF:

SELF ANALYSIS:

STUDENT/ INTERN SIGN: SIGN OF THE PHYSIOTHERRAPIST

NOTE:

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