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Edit Clinical Notes AOHC - Chiropody
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Patient History Referral Source:
Length of Time:
Name of Referral:
Internal External Self
Patient Complaint: Improving:
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c d e f g
Unchanging: g c d e f Worsening:
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c d e f g
What time of day is it worst? AM PM NOON Upon waking Bedtime
What makes it worse?
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Previous History: g c d e f History Comments:
Treatment Comments:
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Radiographs: g c d e f Radiograph Comments:
Hair / Skin / Nails Comments:
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General Health Comments:
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Vascular Assessment Bottom Foot: Diabetes: Yes No Diabetes Comments:
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6 Smoker Comments:
Smoker: Yes No
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6 Left Foot Inner:
Right Foot Inner:
Left Foot Outer:
Right Foot Outer:
Left Foot PT Pulse:
Right Foot PT Pulse:
Left Foot DP Pulse:
Right Foot DP Pulse:
Left Foot Edema: Yes No
Right Foot Edema: Yes No
Left Foot Int. Claudication: Yes No
Right Foot Int. Claudication: Yes No
Left Foot Rest Pain: Yes No
Right Foot Rest Pain: Yes No
Left Foot Diabetes Related Amputation: Yes No Left Foot Vascular Comments:
Right Foot Diabetes Related Amputation: Yes No Right Foot Vascular Comments:
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Sensory Testing Left Foot Light Touch: 1 2 3 4 5 Left Foot Achilles Tendon Reflex: Yes
Right Foot Light Touch: 1 2 3 4 5 Right Foot Achilles Tendon Reflex: Yes No
No Left Foot Patellar Tendon Reflex: Yes No
Right Foot Patellar Tendon Reflex: Yes No
Left Foot Proprioception: Yes No
Right Foot Proprioception: Yes No
Left Foot Deep Pressure: Yes No
Right Foot Deep Pressure: Yes No
Left Foot Autonomic Neuropathy: Yes No
Right Foot Autonomic Neuropathy: Yes No
Left Foot Sensory Comments:
Right Foot Sensory Comments:
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Pain Left Foot Pain Comments:
Right Foot Pain Comments:
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Vascular Left Foot Hair Loss: Yes No
Right Foot Hair Loss: Yes No
Left Foot Cold Skin: Yes No
Right Foot Cold Skin: Yes No
Left Foot Pallor/Cyanosis: Yes No
Right Foot Pallor/Cyanosis: Yes No
Left Foot Edema (weeping): Yes No
Right Foot Edema (weeping): Yes No
Left Foot Cap. Refill (3 sec): Yes No
Right Foot Cap. Refill (3 sec): Yes No
Left Foot Vascular Comments:
Right Foot 5 Vascular Comments:
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Type (Appearance) Left NWB: Yes No
Left WB: Yes No
Right NWB: Yes No
Left Foot Type Comments:
Right WB: Yes No
Right Foot Type Comments:
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Subtalar Joint Left Foot Hypermobile: Yes No
Right Foot Hypermobile: Yes No
Left Foot Within Normal Limits: Yes No
Right Foot Within Normal Limits: Yes No
Left Foot Limited/Decreased: Yes No
Right Foot Limited/Decreased: Yes No
Left Foot Subtalar Joint Comments:
Right Foot Subtalar Joint Comments:
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Halux Dosiflexion Left Foot Average (60-90 deg): Yes No
Right Foot Average (60-90 deg): Yes No
Left Foot Limitus: Yes No
Right Foot Limitus: Yes No
Left Foot Rigidus: Yes No
Right Foot Rigidus: Yes No
Left Foot Halux Dosiflexion Comments:
Ankle Range of Motion
Right Foot Halux Dosiflexion Comments:
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Left Foot Dorsiflexion - Adequate: Yes No
Right Foot Dorsiflexion - Adequate: Yes No
Left Foot Dorsiflexion - Limited: Yes No
Right Foot Dorsiflexion - Limited: Yes No
Left Foot Plantarflexed - With Pain: Yes
Right Foot Plantarflexed - With Pain: Yes
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Left Foot Plantarflexed - With Pain: Yes No
Right Foot Plantarflexed - With Pain: Yes No
Left Foot Ankle Range of Motion Comments:
Right Foot Ankle Range of Motion Comments:
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Toe Positions Left Foot Hallux Abducto Valgus (Bunion): Yes No
Right Foot Hallux Abducto Valgus (Bunion): Yes No
Left Foot Claw Toes: Yes No
Right Foot Claw Toes: Yes No
Left Foot Hammer Toes: Yes No
Right Foot Hammer Toes: Yes No
Left Foot Retracted (1st toes): Yes No
Right Foot Retracted (1st toes): Yes No
Left Foot Straight (normal): Yes No
Right Foot Straight (normal): Yes No
Left Foot Toe Position Comments:
Right Foot Toe Position Comments:
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1st Ray Position Left Foot Plantar Flexed: Yes No
Right Foot Plantar Flexed: Yes No
Left Foot Hypermobile: Yes No
Right Foot Hypermobile: Yes No
Left Foot Normal: Yes No
Right Foot Normal: Yes No
Left Foot Rigid: Yes No
Right Foot Rigid: Yes No
Left Foot Dorsiflexed: Yes No
Right Foot Dorsiflexed: Yes No
Left Foot 1st Ray Position Comments:
Gait Analysis
Right Foot 1st Ray Position Comments:
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Gait Analysis Comments:
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