SUBJECTIVE
Medical Hx:
Surgical Hx:
Medication Hx:
Allergy Hx:
Family Hx:
Social Hx:
Footwear Hx:
Pain Hx:
N - Nature
I – Intensity (rate out of 10)
L - Location
D - Duration
O - Onset
C – Concomitant Factors
A – Aggravating Factors
R – Relieving Factors
T – Treatment
Reflex
OBJECTIVE
0 – absent
1 – reduced (hypoactive)
Neurological:
-
-
-
-
2 – normal
Monofilament
1/3 – inadequate
2/3 – possible
inadequate
3/3 – normal
Motor/Reflexes 3 – increased (hyperactive)
o Patella
Protective sensation
5 – clonus (involuntary due to nerve disorder)
o Achilles
Sensory
o Monofilament (Plantar Hallux, PMA 3 & 5)
10 sites: Plantar 1, 3, 5 digits, PMA 1, 3, 5, Medial +
Lateral Arch, Middle plantar heel, Interdigital hallux
and 2nd toe)
Vibration perception
o Apex hallux, Lateral 5th MPJ, Medial 1st MPJ, medial malleolus, lateral
malleolus, tibial tubercle
0 – absent
Light Touch
1 – altered
o L4 – Medial malleolus
rd
o L5 – Dorsum of foot, 3 MPJ
2 – normal protective sensation
o S1 – Lateral Heel
Vascular:
-
-
Pulses
o PT
o DP
Perfusion
SVPFT
Doppler
o DP
o PT
o Monophasic/biphasic/triphasic
Grading (0-4)
-
0 – No pulse
1 – Feeble pulse
2 – Normal
3 – Bounding
4 – Aneurysmal
Rhythm
-
Regular
Irregular
Rate (bpm)
Musculoskeletal/MSK:
-
-
-
-
-
<1 y/o (100-120 bpm)
Adult (65-80 bpm)
Athlete (<50 bpm)
Stance assessment
o Pes Planus
o Neutral
SVPFT
o Pes Cavus
- <3-5 s – adequate
Global Muscle Testing
- >5s delayed
o Inversion
- >10s significant disease
o Eversion
o Dorsiflexion
o Plantarflexion
Passive ROM
o Ankle
 Do with flexed knees to eliminate effects of gastrocnemius
 Dorsiflexion – minimum 10 degrees
 Plantarflexion – minimum 50 degrees
o Subtalar Joint
 Total 30 degrees of motion with 2X more inversion
o MTPJ
Strength Assessment
o Inversion
o Eversion
o Dorsiflexion
o Plantarflexion
Dermatological
Gait
Footwear
ASSESSMENT:
DX:
DDX
Under each heading if applicable:
-
Neuro
Vasc
MSK
Derm
Gait
Footwear
PLAN;
Short Term
Long Term
Treating Student(s):
Observing Student:
Supervisor:
Instrument Batch No. and I.D: