FATHERMULLERMEDI

CALCOLLEGEHOSPI
TAL
Kankanady
,Mang
alor
e-5
75002,Ph
one:
2238289
Depar
tmentofPh
ysi
oth
erapy

Demog
raph
icdet
ail
s
Name……………………………………………………………….
.
.Ag
e……………………….
Gender
…………………………….
Dat
eofAdmi
ssi
on…………….
Dat
eofAs
ses
sment
…………………Oc
cupat
ion………………………………….
.
Mar
itals
tat
us………………….
.
Addr
ess
…………………………………………………P.
T.No…………………………….

Ch
iefc
ompl
aint
s

SUBJ
ECTI
VEEXAMI
NATI
ON

Hi
stor
y

Hi
stor
yofpr
esent
ingi
ll
nes
s:

Pai
nhi
stor
y:

BodyCh
art
Ar
ea:

Ons
et:

Ty
pe:

Ag
grav
ati
ngf
act
ors
:

Rel
iev
ingf
act
ors
:

I
ntens
ity
:

Sev
eri
ty:

I
rri
tabi
li
ty:

24h
ourpat
ter
n:

As
soc
iat
edFeat
ures
:

Pas
thi
stor
y:

Medi
calHi
stor
y:

Sur
gic
alHi
stor
y:

Gener
alh
eal
th:

2
Per
sonalh
ist
ory
:

Env
ironment
alh
ist
ory
:

Soc
io-
economi
chi
stor
y:

OBJ
ECTI
VEEXAMI
NATI
ON

Obs
erv
ati
on:

I
nfor
mal
:

Pos
tur
e:

Gai
t:

Loc
alobs
erv
ati
on:

Pal
pat
ion:

Ski
n/s
uper
fic
ialf
asc
ia:

Mus
cle:

Bone:

Tender
nes
s:

Swel
li
ng:

Onex
ami
ntat
ion:

ROM:

RI
GHT LEFT
AROM ROM Pai
n Qual
it
y AROM ROM Pai
n Qual
it
y

3
 RI
GHT LEFT
PROM ROM Pai
n EndFeel PROM ROM Pai
n EndFeel

Ac
ces
oor
yMov
ement
s/J
ointPl
ay:
Hypomobi
le

Hy
per
mobi
le

Mus
cles
treng
th:

MMT

RI
GHT LEFT
Mov
ement Gr
ade Mov
ement Gr
ade

Mus
clel
eng
th:

Li
mbLeng
thDi
scr
epenc
y:

Appar
ent

Tr
ue

4
Seg
ment
al

Neur
olog
icalEx
ami
nat
ion

Sens
ory

Mot
or

Ref
lex
es

Spec
ialt
est
s:

Pr
ovi
sionalDi
agnos
is:

I
mpai
rment
s:

Func
tionall
imi
tat
ions
:

Par
tic
ipat
oryr
est
ric
tions
:

5
Goal
s

Sh
ortt
ermg
oal
s:

Longt
ermg
oal
s:

Pl
an/Manag
ement
: