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Musculoskeletal Assessment Format SCOP
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Musculoskeletal Assessment Format SCOP
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Assessment 1
Corporate Governance assignment 1.Full description
THE SARVAJANIK COLLEGE OF PHYSIOTHERAPY, SURAT Hajee A.M. Lockhat & Dr. A.M. Mulla Sarvajanik Hospital, Surat MUSCULOSKELETAL PHYSICAL THERAPY ASSESSMENT
Name: ________________________ _______________________________________________ _______________________
Date: ________________
Age/Sex: __________
Occupation: _____________________
OPD No.: ____________
Address: __________________________ _____________________________________________ ___________________
Ref Dept.: ____________
___________________________________________________ _________________________ ____________________________ __
Handedness: __________
Contact No.: __________________________________________________________________ Height (cm): _________
Weight (kg): _______________
2
BMI (kg/m ): ________
Medical Diagnosis (if any): _____________________________ ____________________________________________________ _________________________ __ Special Precautions (if any): ____________________________ ____________________________________________________ ________________________ Chief Complaint:
Present H/O:
Pain H/O:
Intensity (NRS): -------------------------------------------------------------------------------------------------------------------------------------(No pain) 0 1 2 3 4 5 6 7 8 9 10 (Maximum)
Page 1 of 6
Onset: Duration: Quality:
Prick / Dull ache / Burning / Throbbing / Pulling / Sharp shooting
Rhythm:
Constant / Intermittent
Manner Of Expressing Pain: Verbal / Facial expression Aggravating Factors: Releiving Factors: Effects Of Pain On Physical Activity:
Getting in/out of bed, Getting in/out of chair, Standing/Walking, Walking up/down stairs, Work activities, Other activities (sitting, cooking, dressing, cleaning, lifting, etc.) Accompanying symptoms: Appetite:
Sleep: Irritability:
Medical / Surgical / Occupational H/O :
Personal History: a. Smoking:
Yes / No Since:_____________
b. Tobacco chewing:
Yes / No Since:_____________
c. Alcohol consumption:
Yes / No Since:_____________
d. Physical / Recreational activity:
Page 2 of 6
Family History:
Socio-economic Status:
Poor / Fair / Good
Investigation:
Vital Signs: Heart Rate:
Respiratory Rate:
/min
Blood Pressure:
/
mmHg
Temperature:
/min
.
C
General Examination: Examination: General Body Built: Posture: Gait:
Local Examination: Examination: Temperature: Swelling: ____________________________ ______________________________ __ Soft / Firm / Hard
Pitting / Nonpitting
Tenderness:
Spasm:
Crepitus:
Attitude of the limbs / body part:
Any other findings:(e.g.,Trophical changes / Scar / Wound):
Page 3 of 6
Range Of Motion: Right
Left Joint--
Date
Active
Passive
Active
Passive
Date
Active
Passive
Active
Passive
Flexion Extension Abduction Adduction IR / Supination / Inversion ER / Pronation / Eversion Other Joint:
Tightness / Contracture / Deformity:
Girth Measurement:
Muscle Power:
Limb Length Measurement:
Functional Evaluation: Upper Limb: Dressing: Combing: Washing: Eating: Perineal and back hygiene: Other: Lower Limb: Walking: Stair Climbing: Squatting: Crossed Leg Sitting: Cycling: Other: Gait Analysis:
FIM :1 – Total Assistance Patient- <25%, Assistant- > 75% 2 – Max. Assistance Patient- 25%, Assistant- 75% 3 – Moderate Assistance Patient- 50%, Assistant- 50% 4 – Minimal Assistance Patient- 75%, Assistant- 25% 5 – Supervision Cues without physical contact 6 – Modified Independence Assistive devices, takes more time 7 – Completely Independent
Page 4 of 6
Special Tests:
Other System Examination:
Cardiovascular / Pulmonary System:
Neuromuscular System:
Any Other System:
PROBLEM LIST:
PFD (Physical & Functional Diagnosis):
PHYSIOTHERAPY MANAGEMENT AIMS:
-Short Term:
-Long Term:
TREATMENT PLAN:
Page 5 of 6
HOME PROGRAM:
ERGONOMIC ADVICES:
Prognosis:
Physical Therapist’s Sign
Page 6 of 6
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