CONSULTATION FORM

PHYSIOTHERAPIST NAME:

R/N:

NAME:

DATE:

AGE:

TIME:

HEIGHT:

WEIGHT:

ADDRESS:

SEX:

OCCUPATION:
Chief Complaint:
_________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

History
:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Medical History : i) Present

:
______________________________________________________________
______________________________________________________________
ii) Past
:
______________________________________________________________
______________________________________________________________

Surgical History :
________________________________________________________________________
________________________________________________________________________

Lifestyle

: Smoking
: Alcohol

Consumption

: Others
___________________________________________

Family History
:
________________________________________________________________________
________________________________________________________________________
Remarks
:
________________________________________________________________________
_______________________________________________________________________

Name

Sex :

R/N :

Date

PHYSICAL ASSESSMENT

ANTERIOR

POSTERIOR

Remarks:

Recommendation:

VITAL SIGNS:
Heart Rate:

Blood Pressure:
Respiratory Rate:
Temperature:
GENERAL OBSERVATION:
Built:

Posture:
Gait:

1)

Antalgic Gait :

2)

Ataxic Gait :

3)

Calcaneal Gait :

4)

Circumductory Gait :

5)

Hand to Knee Gait :

6)

High Stepping Gait :

7)

Jack Knifing Gait :

8)

Lordotic Gait :

9)

Scissoring Gait :

10)

Talus Gait :

11)

Trendlenburg Gait :

12)

Valgus Gait :

13)

Varus Gait :

14)

Waddling Gait :

15)

Others: ___________________________

Deformities:

LOCAL OBSERVATION:
Inflammation :
Swelling :
Scar :
Skin :
Muscle Wasting :

PALPATION:
Swelling : Pitting / Non Pitting

Tenderness :
Grade :

Warmth
Crepitus :

Scar : Heal / Non Heal

SENSORY EXAMINATION:
Superficial Sensations:
a) Pain:

Nature:

Mode of Onset:

Course (If Radiates):

Aggravating Factors:

Relieving Factors:

Visual Analogue Scale:

______________________________________________________________
0

10

b) Touch: Normal / Anesthesia / Hyperesthesia / Hypoesthesia

c) Temperature:
Hot Test Tube:
Cold Test Tube:

Deep Sensations:
Propioception:
Kinesthesia:
Vibrations:

Cortical Sensations:
Graphesthesia:
Stereognosis:
Tactile Localization:
2 Point Discrimination:

Superficial Reflexes:
Corneal Reflexes:
Abdominal Reflexes:
- Epigastric Region (T7 T9):
- Upper Abdominals (T9 T11):
- Lower Abdominals (T11 T12):
Anal Reflex (S4 S5):
Plantar Reflex:

Deep Tendon Reflexes:

Biceps:
Brachioradialis:
Triceps:
Knee:
Medial Hamstring:
Lateral Hamstring:
Ankle:

RANGE OF MOTION:
JOINT

Rt.
(ACTIVE)

Lt.
(ACTIVE)

Rt.
(PASSIVE)

Lt.
(PASSIVE)

END FEEL

PAIN

MUSCLE POWER:
MUSCLE

Rt.

Lt.

Rt.

Lt.

Rt.

Lt.

LIMB LENGTH:
True
Apparent
Pelvic Square:
Segmental Limb Length:
Humeral

Ulnar
Femoral
Tibia
MUSCLE GIRTH:
Rt.

Lt.

Arm
Forearm
Quadriceps
Calf
BALANCE:

Static:
Sitting (With eyes open & closed) =
Standing (With eyes open & closed) =
Tendem Standing (With eyes open &

closed) =

Dynamic:
Reaching out activities : Able / Unable
Pertuberation: Able / Unable

GAIT ANALYSIS:

Stance Phase:
Swing Phase:
Step Length:
Stride Length:
Base Width:
Cadence:
Other:

FUNCTIONAL EVALUATION OF UPPER LIMB:

Dressing: YES / NO
Combing: YES / NO
Washing: YES / NO
Eating: YES / NO
Toileting: YES / NO
Other: YES / NO

FUNCTIONAL EVALUATION OF LOWER LIMB:

0 unable to do
1 - With human
support
2 using aid
3 needs
supervision
4 - independent

 Stair Climbing: YES / NO

Cycling: YES / NO
Other: YES / NO
INVESTIGATIONS:

Pathological Findings:

Radiological Findings:

SPECIAL TEST:

DIFFERENTIAL DIAGNOSIS:

DIAGNOSIS:

PHYSIOTHERAPY AIMS:

To relieve pain
To increase ROM
To correct deformity
To relieve stiffness
To improve muscle power & strength
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)

INSTRUCTIONS BY THE PHYSIOTHERAPIST:

DATE OF EVALUATION:
PHYSIOTHERAPIST: