SHOULDER INITIAL EVALUATION
Name of Patient:
Date:
MD:
Diagnosis:
Date of Injury:
Date of Surgery:
SUBJECTIVE
Mechanism of Injury:
Subjective Complaints:
OBJECTIVE
Upper Extremity ROM:
Left shoulder clearing
Right shoulder clearing
WNL
Restricted as follows:
WNL
Restricted as follows:
AROM/PROM
R
MMT (5-Normal, 4-good, 3-fair, 2-poor)
R
L
ER
IR
Scaption
Abduction
L
Flexion
Abduction
Horiz Adduction
ER
IR
Posture/Observation:
Palpation/Tenderness:
Optional Test (+/-) : (As indicated by condition)
Neer’s impingement:
Empty can:
Hawkin’s-kennedy:
Anterior drawer:
Apprehension:
Relocation:
Distraction/instability:
Capsular pattern:
NEUROLOGICAL ASSESSMENT:
Areas of numbness/tingling/pins & needles:
Dermatomes involved:
C ½ upper trap
C5 bicep
C3 deltoid
C6 tricep
C4
C8 hallux ext
SUGAR LAND/STAFFORD
711 AVENUE E
STAFFORD, TX 77477
GRAND PARKWAY/KATY
7830 W GRAND PKWY S
RICHMOND, TX 77406
WILLOW BROOK
12539 PERRY RD
HOUSTON, TX 77070
ASSESSMENT
Name of Patient:
CURRENT PROBLEMS:
DECREASED ROM
JOINT HYPOMOBILITY
JOINT HYPERMOBILITY
DECREASED STRENGTH
SOFT TISSUE DYSFUNCTION
MUSCLE ATROPHY
SWELLING
BALANCE DEFICITS
NEUROLOGICAL INVOLVEMENT
ADL DIFFICULTY
FUNCTIONAL DEFICITS:
DRESSING
REACHING
ADL DEFICIENCY
SLEEPING
DRIVING
OVERHEAD ACTIVITIES
CARRYING
LIFTING
WORK STATUS:
OCCUPATION:
STATUS:
UNABLE TO WORK
PART TIME
RESTRICTED DUTY
FULL TIME
FULL DUTY
PLAN
INITIAL GOALS:
1.
2.
3.
TREAMENT PLAN:
THERAPEUTIC EXERCISE
MODALITIES
MANUAL THERAPY
TREATMENT FREQUENCY:
NEUROMUSCULAR RE-ED
GAIT TRAINING
HOME EXERCISE PROGRAM
TIMES/WK FOR
WEEKS
____________________________________
Apryl Neal, PT, DPT, ATC, LAT
____________________________________
, MD
SUGAR LAND/STAFFORD
711 AVENUE E
STAFFORD, TX 77477
GRAND PARKWAY/KATY
7830 W GRAND PKWY S
RICHMOND, TX 77406
WILLOW BROOK
12539 PERRY RD
HOUSTON, TX 77070