Musculoskeletal Assessment Format SCOP

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)

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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:

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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):

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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

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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:

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HOME PROGRAM:

ERGONOMIC ADVICES:

Prognosis:

Physical Therapist’s Sign

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