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Edit Clinical Notes AOHC - Physiotherapy
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Physiotherapy History: Current History:
Investigations:
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5
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6
Medications:
Past History:
5
5
6
6
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Physiotherapy Pain Assessment: Present Pain:
5
Sleep disturbed: Yes No
Pain worse in: Morning Night Day Changes
Irritability: Yes No
6 Aggravated by:
Eased by:
5
5
6
6
Activity:
Morning Pain Comments:
5
5
6
6
Night Pain Comments:
Sites of Pain and Paraesthesia:
Day Changes for Pain Comments:
5
5
6
6
i Narrative View n j k l m n j Template View k l m Sensory Loss: Yes No Pain Comments
Pain Scale (1 – 10):
5
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Sensory Testing Light Touch: Normal/Adequate Function Abnormal/Inadequate Function Not Evaluated
Temperature: Normal/Adequate Function Abnormal/Inadequate Function Not Evaluated
Reflexes: Normal/Adequate Function Abnormal/Inadequate Function Not Evaluated
Proprioception: Normal/Adequate Function Abnormal/Inadequate Function Not Evaluated
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Additional Testing: Behaviour / Communication: Normal Abnormal Not Evaluated
Posture: Normal Abnormal Not Evaluated
Behaviour / Communication Comments:
Posture Comments:
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5
6
6
Skin: Normal Abnormal Not Evaluated
Coordination: Normal Abnormal Not Evaluated
Skin Comments:
Coordination Comments:
5
5
6
6
Balance: Normal Abnormal Not Evaluated
Transfers: Normal Abnormal Not Evaluated
Balance Comments:
Transfers Comments:
5
5
6
6
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Assistive Normal Devices: Abnormal Not Evaluated
ADL: Normal Abnormal Not Evaluated ADL Comments:
Assistive Devices Comments:
5
5
6
6
Gait: Normal Abnormal Not Evaluated Gait Comments:
5
6
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Physiotherapy Database: Articular:
Other Findings:
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5
6
6
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Analysis Subjective / Objective:
Analysis:
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5
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6
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Fall History Has patient ever fallen? Yes No
Dizziness: Yes No Unknown
Dark: Yes No Unknown
Blurred Vision: Yes No Unknown
Date of fall:
Irregular Heart: Yes No Unknown
Near faint / syncope: Yes No Unknown
Time of day:
Weakness: Yes No Unknown
Location of fall:
Fall / syncope: Yes No Unknown
Wearing shoes: Yes No Unknown
5
6
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Activity associated with fall:
Body part(s) struck in fall:
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5
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6 Object struck:
Injuries sustained in fall:
5
5
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6
Other Comments:
5
6
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Social / Environmental Factors: Lives Alone: Yes No
Friends / Relatives Nearby:
5
Friends / Relatives Nearby: Yes No Asst. from Friends / Relatives: Yes No
6 Activity Type:
Activity Level: Indoor only Indoor and Outdoor
5
Community Activity: Yes No
6
Exterior Stairs: Yes No
Exterior Stairs Railing: Yes No
How many external stairs?
Interior Stairs: Yes No
Interior Stairs Railing: Yes No
How many internal stairs?
Walking Aid: Yes No Smoker: Yes No
Walking Aid Type:
How many cigarettes per day:
Assistance with Meals / Grocery: Yes No Alcohol
Assistance with Self Care:
Assistance with housekeeping:
Yes No How often do you
How
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Alcohol Use: Yes No
How much alcohol?
How often do you drink alcohol? Daily Weekly Less Frequently
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Medical / Surgical History Respiratory Disease: Yes No
Hearing: No obvious defects Using Assistive Device Abnormal Findings
Osteoporosis: Yes No
Nails: No Clubbing or Cyanosis Abnormal Findings
Cancer: Yes No
Feet: No Deformity/Lesions/Tenderness Abnormal Findings
Orthopaedic Surgery: Yes No
Footwear: Supportive/Safe/Well Fitting Abnormal Findings
Cardiovascular Disease: Yes No
Mental Status: Alert and Attentive Recall Month/Day/Year/Time Abnormal Findings
Diabetes: Yes No Neurological Disease: Yes No Vision: Yes No
Relevant Diagnostic Imaging Results: Yes No
Coordination: Normal Rapid Alternating Movement Abnormal Findings Sensation: Normal Light Touch and Proprioception Abnormal Findings Relevant Diagnostic Imaging Results Comments:
5
6
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Motor and Range of Motion (ROM): Sitting balance – steady / safe when upright Yes No
TUG (sec):
5
Sit to stand – able to rise with arms folded Yes No Standing balance – steady in narrow stance Yes No
6
Gait Initiation – no hesitancy Yes No Berg /56: Step length – each ft passes stance ft, clears ft Yes No
5
Step symmetry – equal step length Yes No Step path – straight with / without walking aid Yes No Step pattern / cadence – continuous, regular steps Yes No
6 Mod.
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No Sit to stand – Safe /Judges distance correctly Yes No Syncope (result of carotid hypersensitivity) Yes No
Mod. Activity specific Balance Confidence Scale:
5
Moderate / severe cognitive impairments Yes No Low bone density Yes No
Gait Velocity m/sec:
6 5
Postural Hypotension Yes No Urinary Incontinence Yes No Vision Yes No
6
Low BMI – indicates HIGH RISK Yes No Previous falls – indicates HIGH RISK Yes No
Gait Description:
5
Impairments of gait – indicates HIGH RISK Yes No Impairments of balance – indicates HIGH RISK Yes No
6
Established RISK for fall: High Moderate Low RANGE OF MOTION
Add Joint
Add Joint:
Joint
Digit
Findings
End Feel
Motion
Measure/Unit Comments
1
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Fall Assessment Analysis: Home / environment assessment completed?
Home / enviornment assessment completed:
5
Yes No Date home/env. assessment was completed:
6 Further home / env. investigation indicated?
Investigation Request made to:
5
Yes No
6 Medication Review Indicated? Yes No
Nutrition Intervention indicated? Yes No
Medication Review Request made to:
Nutrition Intervention Request made to:
5
5
6
6
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Problems Related to Fall Risk: Problems Related to Fall Risk: De-conditioning ROM Muscle Strength Balance Safety with transfers Safety with ambulation Impaired cognition
Other Problems Related to Fall Risk:
5
6
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Lower Extremities Functional Scale: Experiences difficulty with lower ext. activities: g c d e f
Lower Extremities Functional Scale: N/A
Any of your work, housework or school activities:
Squatting:
Your hobbies, recreational or sporting activities:
Walking two blocks:
Getting into or out of the bath:
Walking a mile:
Lifting an object from the floor:
Going up or down 10 stairs:
Putting on your shoes or socks:
Standing for one hour:
c d e f g
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Making sharp turns while running fast:
Hopping:
Walking between rooms:
Rolling over in bed:
Performing light activities around home:
Sitting for one hour:
Performing heavy activities around home:
Running on even ground:
Getting into or out of your car:
Running on uneven ground:
Total score / 80
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Neck and Scapulae: Neck Flexors: C1 – 7:
Scapulae – Depressor: CNXI C2 – 4:
5
5
6
6
Neck Extensors: C1 - 7:
Scapulae – Retractors: CNX1 C2 – 4:
5
5
6
6
Neck Flexion / Rotation: C2 - 3:
Scapulae – Retractors: C4 – 5:
5
5
6
6
Scapulae – Elevators: CNXI C2 - 4:
QuickDASH - Disabilioty/Symptom Score
Scapulae – Protractors: C5 - 8:
5
5
6
6
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Experienced difficulty with activities this week: g c d e f Open tight or new jar: Yes No Do heavy household chores: Yes
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Do heavy household chores: Yes No Carry a shopping bag or briefcase: Yes No Wash own back: Yes No Use a knife to cut food: Yes No Activities where force/impact through arm/shoulder/hand: Yes No Arm/shoulder/hand problem interfered with normal social activities: Yes No Patient limited in work/other activities due to arm/shoulder/hand problem: Yes No
Experienced symptom severity this week: g c d e f Arm, shoulder or hand pain: Yes No Tingling in arm, shoulder or hand: Yes No Difficulty sleeping due to pain in arm/shoulder/or hand: Yes No
Disability/Symptom {[(sum of 'n' responses0/'n']-1
Spinal Assessment:
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Cervical:
c d e f g
Thoracic:
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Cervical:
Thoracic:
5
5
6
6
Lumbar:
Sacral:
Lumbar:
Sacral:
Back Palpation:
5
5
6
6
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Back Palpation:
5
6
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Subjective Back Pain Assessment:
Subjective Back Pain Assessment: N/A g c d e f I stay at home most of the time because of my back Yes No It is difficult to turn over in bed due to back Yes No I change positions frequently to get comfortable Yes No My appetite is not very good due to back pain Yes No I walk more slowly than usual because of my back Yes No I have trouble putting on socks/stockings due to b Yes No Due to back, I'm not doing usual jobs and home Yes No I only walk short distances because of back pain Yes No Due to back, I try to get others to do things for Yes No I sleep less because of my back Yes No Due to back, I hold onto objects to get out of cha Yes No Due to back pain, I get dressed with help Yes No I get dressed more
Yes No
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more I sit slowly Yes down No than for usual most of I only stand for short periods due to back Yes due to No the day back because I avoid jobs around the house because of my back Yes of my No back Due to back, I try not to bend or kneel down Yes No Due to back pain I am more irritable & bt than usu Yes No I find it difficult to get out of a chair due to b Yes No Due to back pain I go up/down stairs more slowly Yes No My back is painful almost all of the time Yes No I stay in bed most of the time because of my back Yes No Over the past 24 hrs how bad was your pain? (1-10)
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