Orthopaedic Assessment
Name
Age
:
Address:
Chief Complaints:
Gender:
Occupation:
Present History:
Mode of Onset:
Duration:
Associated Problem:
Course:
Past Medical History:
Birth History:
History of other diseases & injuries:
Operations & Hospitalizations:
Medications:
Physiotherapy Treatment:
Personal History:
Personal Habits:
Marital Status:
Family History:
Similar Problem in relatives:
Hereditary Diseases:
Consanguinity:
Infections:
Economical History:
Income:
Source:
Social History:
Social Status:
Educational Status:
Environmental History:
Environment of Home:
Environment of Workplace:
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Vital Signs:
Heart Rate:
Blood Pressure:
General Observation:
Built:
Posture:
Gait:
o Antalgic Gait:
o Ataxic Gait:
o Calcaneal Gait:
o Circumductory Gait:
o Hand to Knee Gait:
o High Stepping Gait:
o Jack Knifing Gait:
Local Observation:
Inflammation:
Swelling:
Scar:
Temperature:
Respiratory Rate:
o Lordotic Gait:
o Scissoring Gait:
o Talus Gait:
o Trendlenburg Gait:
o Valgus Gait:
o Varus Gait:
o Waddling Gait:
o Other:
Deformities:
Skin Condition:
Muscle Wasting:
Shape Alteration:
Palpation:
Swelling:
Pitting, Non-Pitting
Tenderness:
Warmth:
Crepitus:
Scar: Heal / Non-Heal / Length
Sensory Examination:
Superficial Sensations:
o Pain:
location:
Nature:
Mode of Onset:
Course (If Radiates):
Aggravating Factors:
Relieving Factors:
Visual Analogue Scale:
0
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10
o Touch: Normal, Anesthesia, Hyperesthesia, Hypoesthesia
o Temperature:
Hot Test Tube (40-45C):
Cold Test Tube (5-10C):
Deep Sensations:
o Propioception:
o Kinesthesia:
o Vibrations:
Cortical Sensations:
o Graphesthesia:
o Stereognosis:
o Tactile Localization:
o 2 Point Discrimination:
Superficial Reflexes:
o Corneal Reflexes:
o Abdominal Reflexes:
Epigastric Region (T7-T9):
Upper Abdominals (T9-T11):
Lower Abdominals (T11-T12):
o Cremastric Reflex (L1-L2):
o Anal Reflex (S4-S5):
o Planter Reflex:
Deep Tendon Reflexes:
o Biceps (C5-C6):
o Brachioradialis (C5-C6):
o Triceps (C7-C8):
o Pectoral (C5-T1):
o Finger Flexion (C6-T1):
o
o
o
o
o
Knee (L3-L4):
Post. Tibial (L4-L5):
Med Hamstring (L5-S1):
Lat. Hamstring (S1S2):
Ankle (S1S2):
Range of Motion:
Joint
Rt.(Active) Lt.(Active) Rt.(Passive) Lt.(Passive) End Feel
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Pain
Muscle Power:
Muscle
Rt.
Lt.
Limb Length:
Rt.
Lt.
Rt.
Lt.
Rt.
Lt.
True
Apparent
Pelvic Square:
Segmental Limb Length:
Humeral
Ulnar
Femoral
Tibial
Muscle Girth:
Arm
Forearm
Quadriceps
Calf
Balance:
Static:
o Sitting (With eyes open & closed)
o Standing (With eyes open & closed)
o Tendem Standing (With eyes open &
closed)
Dynamic:
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0 Unable to do
1 With Human Support
2 Using Aid
3 Needs Supervision
4 - Independent
o Reaching out activities: Able/Unable
o Perturbation: Able/Unable
Gait Analysis:
Stance Phage:
Swing Phage:
Step Length:
Stride Length:
Functional Evaluation of Upper Limb:
Dressing:
Combing:
Washing:
Eating:
Toileting:
Other:
Functional Evaluation of Lower Limb:
Stair Climbing:
Cycling:
Other:
Investigations:
Pathological Findings:
Radiological Findings:
Special Tests:
Differential Diagnosis:
Diagnosis:
Physiotherapy Aims:
To relieve pain
To increase ROM
To correct the deformity
To relieve stiffness
To improve muscle power & strength
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Base Width:
Cadence:
Other:
To improve muscle endurance
To maintain tissue extensibility
To correct posture
To improve balance
To train for walking aids
Gait training
Other
Short Term Goals:
Long Term Goals:
Physiotherapy Plan:
HEP (Home Exercise Program):
Ergonomics:
Instructions by the Therapist:
Date of Evaluation:
Therapist
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