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Edit Clinical Notes AOHC - Physiotherapy

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Physiotherapy History: Current History:

Investigations:

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Medications:

Past History:

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5

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Physiotherapy Pain Assessment: Present Pain:

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Sleep disturbed: Yes No

Pain worse in: Morning Night Day Changes

Irritability: Yes No

6 Aggravated by:

Eased by:

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5

6

6

Activity:

Morning Pain Comments:

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5

6

6

Night Pain Comments:

Sites of Pain and Paraesthesia:

Day Changes for Pain Comments:

5

5

6

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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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Skin: Normal Abnormal Not Evaluated

Coordination: Normal Abnormal Not Evaluated

Skin Comments:

Coordination Comments:

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Balance: Normal Abnormal Not Evaluated

Transfers: Normal Abnormal Not Evaluated

Balance Comments:

Transfers Comments:

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Assistive Normal Devices: Abnormal Not Evaluated

ADL: Normal Abnormal Not Evaluated ADL Comments:

Assistive Devices Comments:

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Gait: Normal Abnormal Not Evaluated Gait Comments:

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Physiotherapy Database: Articular:

Other Findings:

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Analysis Subjective / Objective:

Analysis:

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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

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Activity associated with fall:

Body part(s) struck in fall:

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6 Object struck:

Injuries sustained in fall:

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Other Comments:

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Social / Environmental Factors: Lives Alone: Yes No

Friends / Relatives Nearby:

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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:

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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

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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

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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:

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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:

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Neck Extensors: C1 - 7:

Scapulae – Retractors: CNX1 C2 – 4:

5

5

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Neck Flexion / Rotation: C2 - 3:

Scapulae – Retractors: C4 – 5:

5

5

6

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Scapulae – Elevators: CNXI C2 - 4:

QuickDASH - Disabilioty/Symptom Score

Scapulae – Protractors: C5 - 8:

5

5

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:

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Lumbar:

Sacral:

Lumbar:

Sacral:

Back Palpation:

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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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