Musculoskeletal Assessment Format SCOP

7/29/2019 Musculoskeletal Assessment Format SCOP

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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): _______________ BMI (kg/m2): ________

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: Sleep:

Appetite: 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: /min Respiratory Rate: /min

Blood Pressure: / mmHg Temperature: .C

General Examination:

General Body Built:

Posture:

Gait:

Local 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

Date Joint-- Date

Active Passive Active Passive 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 AssistancePatient- <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 IndependenceAssistive 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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Musculoskeletal Assessment Format SCOP