0196-6011/84/0506-0348$02.00/0
THEJOURNAL
OF ORTHOPAED~C
AND SPORTS
PHYSICAL
THERAPY
Copyright O 1984 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association
The Use of Standardized Evaluation
Forms in Physical Therapy
Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
JOHN P. TOMBERLIN, PT,* JOHN S. EGGART, MS, PT, ATC,t LORI CALLISTER, PT, ATCt
The need for a consistent and efficient method of patient evaluation is not a new one.
Standardized evaluation forms that include body charts can be useful in recording
subjective and objective data in a systematic way. At the Physical Therapy UnitStudent Health Center, University of Wisconsin-La Crosse, we have designed and put
into use this type of evaluation form.
We feel these evaluation forms allow us to perform consistent and efficient patient
evaluations in a short amount of time, especially for acute musculoskeletal injuries. A
method of controlling consistency is very important because of physical therapy and
athletic training students and interns that rotate through the Physical Therapy Unit.
Because of the large volume of patients we see, there is a need for reducing the
amount of time needed in longhanding subjective, objective, assessment, and
planning (S.O.A.P.) notes. The standardized evaluation forms are an efficient
alternative to the longhand S.O.A.P. note.
The need for a consistent and efficient method
of patient evaluation is not a new one. Standardized evaluation forms that include body charts can
be useful in recording subjective and objective
data in a systematic way. At the Physical Therapy
Unit-Student Health Center, University of Wisconsin-La Crosse, we have designed and put into
use this type of evaluation form.
We use a specific evaluation form depending
on the body area involved. Currently we have
divided the body into nine areas and have nine
corresponding evaluation forms: Cervical Spine
(Fig. 1); Anterior Torso (Fig. 2); Lumbar Spine and
Sacroiliac (Fig. 3); Distal Forearm, Wrist, Hand,
Thumb, and Fingers (Fig. 4); Proximal Forearm
and Elbow (Fig. 5); Shoulder (Fig. 6); Hip and
Thigh (Fig. 7); Knee (Fig. 8); Lower Leg, Ankle,
and Foot (Fig. 9). Evaluation forms specifically for
gait and posture are being compiled. (Currently
there is not an evaluation form for the thoracic
spine.) This list of evaluation forms is not necessarily a complete one, and further subdivisions of
the body areas may be needed.
Intern, Spring 1983, Mayo Foundation School of Allied Health Sciences.
t Clinical Supervisors: Student Health Center-Physical Therapy Untt,
University of Wisconsin-La Crosse, La Crosse, WI 54601.
The format of the forms is divided into four
sections: subjective, objective, assessment, and
planning (S.0.A.P.).8,'3There are s'imilar features
to all the evaluation forms. The subjective section
includes the following common items:
-the mechanism of injury
-previo~;s history of injury
-any pain, edema, numbness, or tingling present now or at time of injury and have they
changed
-did the patient hear or feel any sounds at
time of injury
-can patient ambulate now or at time of injury
without limp or pain (lower extremity injury)
Each objective section includes body charts to
mark findings of observation and palpation including any edema, deformity, discoloration, tenderness, crepitus, etc., present. There is at least one
body chart per form usually with the skeletal
system outlined in the body part or area. Generally, the body charts include anterior, posterior,
medial, and lateral views. One set of body charts
is for marking observation and palpation findings2
as previously mentioned, and another set is for
marking sensation test findings. The rest of the
objective section includes:
-norms for AROM and pROM4 using the
S.F.T.R. method of recording7
JOSPT MaylJune 1984
349
STANDARDIZED EVALUATION. FORMS
Social Security # :
PIiYS I CAL THERAPY UEI I T
Student H e a l t h Center
U n i v e r s i t y o f Wisconsin-La Crosse
CERVICAL SPINE EVALUATION FORM
Name :
Date o f i n j u r y :
S:
P a i n f u l area:
--
R
or
L
or
B
or
Center
-PT :
Date o f i n i t i a l evaluation-TR
Mechanism o f i n j u r y :
Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
H i s t o r y o f previous i n j u r y :
What k i n d o f p a i n does p a t i e n t have?
\(he r e ?
What changes p a i n and how
Constant p a i n
or
i n t e r m i t t e n t pain,
..........
..........
....
..........
Dizziness
Stiffness
rlumbness o r t i n a l i n a ?
\,leakness?
Other medical problems?
Ned i c a t i o n s ?
Docs p a t i e n t use a p i l l o w ?
d
2
...
........
Comments:
0:
.
Y
Y
Y
Y
Y
Y
Y
or
or
or
or
or
or
or
N
N
N
N
N
E.4
N
Pain more severe?
\dhen?
Where?
\/here7
Where?
What?
!,/hat?
\./hat k i n d ?
A.M.
or
P.M.
When?
'
Observe and p a l p a t e f o r s w e l l i n g ,
and mark on body c h a r t .
Special t e s t s :
Compression
Distraction
Valsalva
Swallowing..
Adson
.... +
.... +
. . . . . .+
. . .+
....... +
or
or
or
or
or
+
or
TMJ P a l p a t i o n
...
d e f o r m i t y , d i s c o l o r a t i o n , tenderness, c r e p i t u s , e t c . ,
-
Fig. 1
JOSPT Vol. 5,No. 6
ROM:
S
F
Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
R
40-0-40
45-0-45
50-0-50
SENSORY: Mark on body c h a r t f o r numbness,
t i n g l i n g , p a r e s t h e s i a , hypoesthesia,
r a d i a t i n g p a i n o r o t h e r symptoms.
MMT :
D e l t o i d (C5, a x i l l a r y N)
Biceps ( ~ 5 , 6 , musculotaneous
W r i s t E x t (C6, r a d i a l N)
F i n g e r F l e x (C8)
F i n g e r Abd ( ~ 1 ) .
..
..
......
......
P:
REFLEXES :
(C5)-Biceps.
=
(Cb) - B r a c h i o r a d i a l i s =
(C7)-Triceps
=
(C8) +!one
(TI ) -None
...
...
.,
.
S h o r t term g o a l s :
-
Mid term g o a l s :
Long t c r m goa 1 s :
AthleticTraining
Eva 1 ua t o r
Date
PhysicalTherapy
Eva 1 ua t o r
Date
PhysicianReview
Date
JOSPT MaylJune 1984
351
STANDARDIZED EVALUATION FORMS
S o c i a l S e c u r i t y hi:
PllYS i CAL THERAPY UNIT
Student H e a l t h Center
U n i v c r s i t y o f Wisconsin-La Crosse
AIITER I OR TORSO EVALUATI ON FORM
Name :
-
Date o f i n j u r y :
S:
P a i n f u l area:
Date o f i n ; t i ; l
R
or
L
or
B
c v a i u ~ t i o n - TR:
or
Center
PT :
biechanism o f i n j u r y o r onset o f p a i n :
-
Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
H i s t o r y o f p r e v i o u s problems:
Kind o f p a i n :
\./hat
f'
pain?
Consistant pain
Y
or
N
\*ihct
6
I n t e r m i t t e n t pain
Y
pa i n ?
or
N
Weakness
Y
or
N
Comments :
0:
Observe and p a l p a t e f o r s w e l l i n g , deformi t y , d i s c o l o r a t i o n ,
and mark on body c h a r t .
Sensory: Nark on body c h a r t f o r
numbness, t i n g 1 i ng , pa.rcs thes ia,
hypoesthesia, r a d i a t i n g p a i n o r
o t h e r symptoms.
Fig. 2
tenderness, c r e p i t u s , e t c . ,
JOSPT Vol. 5, No. 6
Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
0 : ROM:
MMT :
Upper r e c t u s abdominus
Lower r e c t u s abdominus
Left
Ext o b l ique
-Riaht
I n t oblique
Left
-Right
-
d
Special t e s t s :
S i t up
Bilateral leg raise
~
Comment s :
P:
S h o r t term g o a l s :
--
Mid term g o a l s :
Long term goa 1 s :
A t h l e t i c Training
Eva 1 ua t o r
Date
---
P h y s i c a l Therapy
Eva 1 ua t o r
Date
P h y s i c i a n Review
Date
JOSPT MaylJune 1984
STANDARDIZED EVALUATION FORMS
PHYSICAL THERAPY UNIT
Student H e a l t h Center
U n i v e r s i t y o f Wisconsin-La Crosse
#:
Social Security
LUIlBAR SPl NE AND SACRO- I L IAC EVALUAT 10'1 FOfil?
Name :
Date o f i n j u r y :
P a i n f u l area: R
or B
or L
or
Center
or
N
PT :
Date o f i n i t i a l e v a l u ~ t i o n - T R :
S : Mechanism o f i n j u r y o r o n s e t o f p a i n :
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
H i s t o r y o f p r e v i o u s i n j u r y o r p a i n episodes:
What k i n d o f p a i n does the p a t i e n t have?
....-. -.
Where?
-
P a t i e n t has p a i n - s t a n d i n o ? Y
Y
-supine?
-coughing? Y
P a t i e n t has p a i n c o n s t a n t l y o r
What changes p a i n and how?
P a t i e n t has o t h e r i l l n e s s ? Y
P a t i e n t on m e d i c a t i o n ?
Y
P a t i e n t n o t i c e d any weakness?
What i s c o n d i t i o n o f p a t i e n t ' s
-
-
or N
sittinq? Y or N
or N
other?
or N
b e a r i n g down? Y o r
intermittently?
-
or N
or N
Y or
bed?
What?
What?
N Numbness?
Observe and p a l p a t e f o r s w e l l i n g ,
d e f o r m i t y , d i s c o l o r a t i o n , tenderness, c r e p i t u s , e t c . , and mark on
body c h a r t .
Y
or
-
prone?
N
No
-
Y
other?
Tingling?
Y
or
N
Sensory:
Mark on body c h a r t f o r numbness, t i n g l i n g , p a r e s t h e s i a ,
h y p e r e s t h e s i a , hypoesthesia,
r a d i a t i n g pain o r other
symptoms.
Leg Length:
0,
Fig. 3
JOSPT Vol. 5, No. 6
0:
ROM:
S 30-0-85
F 30-0-30
Reflexes:
( ~ 4 )Knee j e r k = , R>L
( ~ 1 )Ankle j e r k a , R ? L
S L R . . . . . . +
or
Reverse SLR
+ or
Babinski
+ or
MHT :
11 i o psoas ( ~ 2 - 3 ) .
Quadriceps ( ~ 3 )
T i b Ant ( ~ 4 )
Ext Hal 1 i c u s ( ~ 5 )
T r i c e p s Surae ( S l )
Hamstrings ( S l )
G l u t Max ( s I ,2)
-
..
,
L7R
, L?R
-
...
..
.......
.
..
..
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
1
Special t e s t s :
Hoover t e s t
Supine-chin t o c h e s t
Raise b o t h legs s t r a i g h t 2".
V a l s a l v a Maneuver...........
S 1 Compression
S 1 Distraction..............
Gaenslin test...............
Patrick's test
Rectus abdominus....
................ +
....... +
+
+
.............. +
+
+
............. +
........ +
.
or
or
or
or
or
or
or
or
or
-
-
-
Supine/Long s i t t i n g test...
Sacral push-cranial
-caudal.........
P a l p a t i o n o f Sacrum
I l i a c Rot-ant
-p ost.............
Hip adduction/flexion
Check PSIS-raise L l e g
-raise R leg
- f l e x trunk
+
........ +
+
........ +
.............. +
...... +
.... +
.... +
..... +
or
or
or
or
or
or
or
or
or
Comments :
P:
S h o r t term g o a l s :
Mid term g o a l s :
Long term goa 1 s :
AthleticTraining
Eva 1ua t o r
Date
PhysicalTIierapy
Eva 1ua t o r
Date
PhysicianReview
Date
.
-
JOSPT MaylJune 1984
PHYSICAL THERAPY UNIT
Student H e a l t h Center
Un i v e r s i t y o f \.lisconsin-La
STANDARDIZED EVALUATION FORMS
Social Security # :
Crosse
HAND, WRIST, FOREARM, THUMB, AND FINGERS EVALUATION
-
Name :
Date o f i n j u r y :
S:
Affected side;
Date o f i n i t i a l evaluation-TR:
R or
L
-PT :
Mechanism o f i n j u r y :
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
H i s t o r y o f previous i n j u r y :
. .Y
or
N
Where?
Has p a t i e n t f e l t any numbness o r t i n g l i n g ? Y
or
N
When?
. . . . . .Y
or
N
Has p a t i e n t f e l t o r heard any sounds?.
Has p a t i e n t f e l t any weakness?
When does p a t i e n t have p a i n ?
When?
Where?
What k i n d ?
Where i s p a i n ?
What makes p a i n change?
0:
Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y
e t c . , and mark on body c h a r t .
Palpation:
Fig. 4
, d i s c o l o r a t ion,
tenderness, c r e p i tus,
356
0:
TOMBERLIN ET AL
Norma 1
ROM:
Wrist
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
MMT :
Active
S D - 60
F
S
S
S
F
F
F
F i n g e r (11P)
(PIP)
(DIP)
Thumb ( I P)
(Mp)
(CM)
W
-- r i s t
Flexion
Extension.
Ulnar deviation
Radial d e v i a t i o n .
Supination.
Pronation
.....
...
.
...
.....
JOSPT Vol. 5, No. 6
Pass i v e
20-0- 30
45-0- 90
0-0-100
10-0-90
10-0- 80
0-0-50
0 - 0 - 15
Finger ---
F l e x NCP..
Ext FICP
F l e x PIP..
Ext PIP
F l e x DIP..
Ext DIP
abd !<CP
add MCP
..
.
..--
.
Special t e s t s :
F l e x o r d i g i t o r u m s u p e r f i c i a l i s t e s t (PIP)
F l e x o r d i g i t o r u m profundus t e s t (DIP)
I n t r i n s i c muscle t i g h t n e s s test...........
Retinaculum t i g h t n e s s test................
Ulnar 6 Radial a r t e r y supply t e s t
D i g i t a l a r t e r y supply t e s t . .
Radial pulse
+
or
or
or
or
or
or
or
or
..... +
.........
..............
+
+
+
+
.............................. =
Thumb
F l e x I1CP..
Ext MCP..
Flcx !?.
E x t 1P
Abd C:1C.
Add CMC..
Oppos i t i o n
-
..-....
..
.
-
Sensory: Mark on body c h a r t f o r
numbness, t i n g l i n g , p a r e s t h e s i a ,
hypoesthesia, hyperesthesia,
r a d i a t i n g p a i n o r o t h e r symptoms.
-
-
R?L
L)R
Comments :
--
P:
-
S h o r t term g o a l s :
Mid t e r m goal s:
Long term goa 1 s :
AthleticTraining
Eva 1 ua t o r
Date
P h y s i c a l Therapy
Eva l ua t o r
-
-
Date
P h y s i c i a n Review
Date
JOSPT MaylJune 1984
STANDARDIZED EVALUATION FORMS
S o c i a l S e c u r i t y #:
PHYSICAL THERAPY UNIT
Student Neal t h Center
U n i v e r s i t y o f Wisconsin-La Crosse
ELBOW AND PROX l IlAL FOREARM EVALUAT l ON FORM
Affected side:
Name :
Date o f i n j u r y :
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
S:
R
Date o f i n i t i a l evaluation-TR:
or
L
or
B
-PT:
Mechanism o f i n j u r y :
H i s t o r y o f previous i n j u r y :
Did p a t i e n t f e e l any pop o r c l i c k ?
......
Y
or
N When?
Y
or
N
When?
Does p a t i e n t f e e l any numbness o r t i n g l i n g now? Y
or
N
Where?
Y
or
N
.............Y
............... Y
or
or
N
N..Where?
Does p a t i e n t f e e l any numbness o r t i n g l i n g ?
Does elbow f e e l s w o l l e n ? .
.
..........
Has s w e l l i n g changed?
Does p a t i e n t have any weakness?
Comments :
0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s l o c a t i o n , d i s c o l o r a t i o n , tenderness,
crepitus, etc.,
and mark on body c h a r t .
Med
Ant
La t
Post
Pal p a t ion:
ROM:
Normal
S
R
Active
0-0-150
90-0- 80
Fig. 5
Passive
JOSPT Vol. 5, No. 6
TOMBERLIN ET AL
HMT :
F l e x i o n (C5,6)
E x t e n s i o n (C7)
S u p i n a t i o n (C5,6).
P r o n a t i o n (C6,8-TI)
Neurological :
ReflexesB i c e p s (C5)
Bracioradialis ( ~ 6 )
T r i c e p s (C7).
...
...
.
.......
...
......
.
Special t e s t s :
Valgus s t r e s s
Varus s t r e s s
Tinel sign
Tennis elbow t e s t .
Compress u l n a & r a d i u s .
. . . . .+
.....
......
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
. .
+
+
+
+
or
or
or
or
or
Sensory: H a r k on body c h a r t f o r numbness, t i n g 1 ing, paresthesia, hypoesthesia, hyperesthesia,
h y p e s t h e s i a , r a d i a t i n g p a i n o r o t h e r symptoms.
-
Comments :
P:
Short term goals:
- -
--
Mid term goals:
Long t e r m goa 1 s :
Athletic Training
Eva1 u a t o r
Date
--
P h y s i c a l Therapy
Evaluator
Date
P h y s i c i a n Review
Date
JOSPT MaylJune 1984
STANDARDIZED EVALUATION FORMS
Social Security #:
PttYS I CAL THERAPY UNIT
Student Hea 1 t h Center
U n i v e r s i t y o f Wisconsin-La Crosse
SHOULDER EVALUATION FORM
Name :
Affected side:
Date o f i n j u r y :
S:
R
or
L
-PT :
Date o f i n i t i a l evaluation-TR:
Mechanism o f i n j u r y :
Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
H i s t o r y o f previous ' i n j u r y :
Did p a t i e n t hear o r f e e l any sound?. Y
or
N
When?
When?
.........
Y
or
N
...
Y
or
N
......Y
............ Y
or
or
N
N
Does p a i n change7
Can p a t i e n t l i e on t h a t s i d e ?
I s the shoulder swollen?
Any change?
When?
Commcn t s :
0:
Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n ,
e t c . , and mark on body c h a r t .
tenderness,
Palpation:
~
ROM:
Normal
S
-
-
-
~
Active
50-0-170
Fig. 6
Passive
crepitus,
JOSPT Vol. 5, No. 6
IlMT :
Flexion ( ~ 5 , 6 )
Extens i o n (C5,6,7,8)
A b d u c t i o n (C5,6)
Adduct i o n ( ~ 5 , 6 , 7 , 8 - T I ) .
E x t . Rot. (C5.6)
I n t . Rot. (C5,6,7,8-TI).
Scapular e l e v a t i o n (C3,4,5).
Scapular r e t r a c t i o n (C5)
Shoulder p r o t r a c t i o n (C5,6,7).
Horizontal Abduction
H o r i z o n t a l Adduction
Neurological :
Reflexes
Biceps (C5)
...........
........
..........
-
, R) L
L7R
Brachioradialis ( ~ 6 )
= , R7L. L 7 R
-Triceps (C7)
= , R)L,
L7R
Sensory: Mark on body c h a r t f o r
numbness, t i n g l i n g , p a r e s t h e s i a ,
hypoesthesia, hyperesthesia,
r a d i a t i n g p a i n o r o t h e r symptoms.
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
......
..........
......
....
......
...
.......
........
Special t e s t s :
Yergason t e s t
Drop arm t e s t
Apprehension t e s t
A-C t r a c t i o n
C l a v i c ! e movement a t A-C.
lmpingment ( l n t . Rot. & F l e x . ) .
Quadrant..
Locking
E i c i p i t a l tendon t e s t
.......... +
...,.......+
........ +
.......... +
.... +
. +
.......... +
..............+
...... +
.=
.
.....
or
or
or
or
or
or
or
or
or
-
-
-
-
-
Comments :
P:
S h o r t term g o a l s :
Mid term g o a l s :
Long term goal s :
A t h l e t i c Training
Eva 1 u a t o r
Date
P h y s i c a l Therapy
Eva 1 u a t o r
Date
P h y s i c i a n Review
Date
JOSPT MaylJune 1984
STANDARDIZED EVALUATION FORMS
PHYSICAL THERAPY U N I T
Student H e a l t h Center
U n i v e r s i t y o f Wisconsin-La Crosse
HIP AND
S o c i a l S e c u r i t y #:
THIGH EVALUATION FORM
Name :
Date o f i n j u r y :
S:
Affected side:
Date o f i n i t i a l e v a l u a t i o n
- TR
R
or
L
or
B
PT
Mechanism o f i n j u r y :
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H i s t o r y o f previous i n j u r y :
Does p a t i e n t f e e l p a i n ?
Y
or
N
Doespatientfeelswelling?
Y
or
N
Where?
What k i nd?
How lono?
.,
What causes change?
Where?
Comments :
0:
Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n , tenderness, c r e p i t u s ,
e t c . , and mark on body c h a r t .
Pal p a t i o n :
Fig. 7
362
0:
TOMBERLIN ET AL
ROM:
-Normal
--
Active
S
15-0-125
F (so)
T(S90)
R(SO)
R (S90)
45-045-045-045-0-
Passive
-
15
20
40
45
MI1T :
MI1T
F l e x o r s ( L 1 ,2,3)
Extensors(S1)
Abductors(L5)
Adductors ( ~ 2 , 3 , 4 )
Ext. Rotators
I n t . Rotators
:
-SEi<SC)RV
--
..
...
...
.
...
...
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JOSPT Vol. 5. No. 6
Mark on body
b o d ~c h a r t f o r numbness,
nu1nbness, t i n g l j n g ,
h y p o e s t: h e s i a , r a d i a t i n g p a i n o r
p a r a t h e s i a , hypoest
- o t h e r symptoms.
-
Special t e s t s :
SLR
Trendelenburg
I l i o - t i b i a 1 band t i g h t n e s s
Hip flexion tightness
Patrick's test
Compress i o n ( l n t Rot & Add)
( E x t Rot & Add).
Leg l e n g t h d i s c r e p e n c y
. . . . . . . . . . . . . . + or . . . . . . . . .+ or . . + or . . . . . + or . . . . . . . . + or . . : + or . . + or . . . . apparent
@
+ or
true
0
+
or
-
Comments :
P:
Short term goals:
- - --
-
-- -
-- -
-- --
--
---
-
M i d t e r m goa 1 s :
Long t e r m goa 1 s :
Ath:etic Trainins
Evaluator
Date
-
P h y s i c a l Therapy
Eva 1ua t o r
Date
P h y s i c i a n Review
--
Date
JOSPT MaylJune 1984
363
STANDARDIZED EVALUATION FORMS
S o c i a l S e c u r i t y #:
PHYSICAL THERAPY UNIT
Student H e a l t h Center
U n i v e r s i t y o f Wisconsin-La Crosse
KNEE EVALUATION FORM
Name :
A f f e c t e d Side:
Date o f i n j u r y :
S:
Date o f i n i t i a l e v a l u a t i o n
- TR
R
or
L
or
B
PT
Mechanism o f i n j u r y :
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H i s t o r y o f previous i n j u r y :
-
p
p
Has t h e knee locked?
Yes
or
No
When?
Has the knee g i v e n o u t ?
Yes
or
No
When?
I s t h e knee s w o l l e n ?
Yes
or
No
When?
Has t h e s w e l l i n g changed? Yes
or
No
How?
Comments :
0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n , tenderness, c r e p i tus, e t c .
and mark on body c h a r t .
Observe g a i t:
-
Palpation:
Fig. 8
364
0:
TOMBERLIN ET AL
ROM:
Normal
(S)
Anthropometric:
R
L
0-0-130
-0
-0
j t l i n e 2 " a b o v e j t l i n e
(5cm)
Knee j e r k r e f l e x =
, R 7 L,
LrR
MMT :
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Active
Active
JOSPT Vol. 5, No. 6
-
R
L
Passive
Passive-
--0-O ----
6"abovejtline
(1 5cm)
Sensory: Mark on body c h a r t f o r numbness, t i n g l i n g ,
paresthesia, hypoesthesia, hyperesthesia,
r a d i a t i n q. ~
. a i no r o t h e r svmotoms.
Quadriceps (L2,3,4)
Hamstrinas (L5-S1)
Abductor;
(~4;5-S
Adductors (L3,4)
Gastroc ( ~ 5 - ~ / 1 , 2 )
S a r t o r i u s (L2,3)
Attach o r t h o t r o n evaluation sheet.
Special t e s t s :
Lachman's
+
Valgus S t r e s s ( f u l l e x t ) .
..+
Varus s t r e s s ( f u l l e x t )
+
Drawer ( a n t )
+
Slocum's R o t a r y ( i n t r o t ) .
+
Apley (comp)
+
Bounce home
. +
1 . l ~H u r r a y (Valgus w i t h e x t r o t )
+
Apprehension
+
P a t e l l a r Grinding
+
P a t e l l a r Ballotment
+
Chondromalacia t e s t s
+
Comments :
............
...
.....
..........
...
..........
..........
.
..........
........
. .. .. .. .. .. ..
P:
or
of
or
or
or
or
or
or
or
or
or
or
.
-
. . . . . .+
. . . . .+
. . . . . . . .+
. . . . . .+
(20°) f l e x
( 2 0 ~ )f l e x ) .
(Post)
(ext r o t ) .
(dis t)
. . . . . . . .+
or
or
or
or
or
+
or
(Varus w i t h i n t .
rot.).
-
.
-
.
.
-
S h o r t term g o a l s :
Mid t e r m g o a l s :
Long t e r m g o a l s :
A t h j e t i c Training
Eva 1 ua t o r
Date
P h y s i c a l Therapy
Evaluator
--
Date
- --
P h y s i c i a n Review
Date
STANDARDIZED EVALUATION FORMS
JOSPT MaylJune 1984
PIIYS I CAL THERAPY UNIT
Student H e a l t h Center
U n i v e r s i t y o f W i sconsi n-La Crosse
S o c i a l S e c u r i t y #:
FOOT, ANKLE, AND LOWER LEG EVALUATION FORM
Name :
Affected side:
Date o f i n j u r y :
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
S:
R
Date o f i n i t i a l e v a l u a t i o n - T R :
or
L
or
B
-PT:
Mechanism o f i n j u r y :
H i s t o r y o f previous i n j u r y :
D i d p a t i e n t hear or f e e l any sound?
..... Y
I s p a t i e n t a b l e t o walk on a f f e c t e d s i d e ?
w i t h o u t 1 imp?
without pain?
i s the ankle swollcn?
Has t h e s w e l l i n g changed?
...
...
....................
................
0:
or
Y
Y
Y
Y
Y
or
or
or
or
or
N
What?
When?
N..at t i m e o f i n j u r y ?
N..at t i m e o f i n j u r y ?
N..at t i m e o f i n j u r y ?
El
N..How?
Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n ,
e t c . , and mark on body c h a r t .
Observe g a i t : ( ~ t t a c hg a i t e v a l u a t i o n i f n o t enough space)
Ankle j e r k r e f l e x
A n t h r o p o m c t r i c ( F i g . 8)
Pulses-Dorsal Pedal
-Posterior Tibia1
-
',
=
=
,
R>L,
R)L,
0
L>R
L>R
L)R
tenderness,
Y
Y
Y
or
or
or
N
N
N
crepi tus,
JOSPT Vol. 5. No. 6
TOMBERLIN ET AL
0:
A c tive
-
ROM:
Ankle
Hind Foot...
Fore Foot
...................
Passive
............
...............
...............
..........
.........
....
.....
.....
G r e a t Toe (MP)
( I?).
2nd t o 5 t h Toes (HP)
Which Toe? (PIP)
(DIP)
SENSORY:
tingling,
MMT :
T r i c e p s Surae ( ~ ,1
2).
T i b Ant ( ~ 4 )
Ankle i n v e r t o r s ( ~ 5 ) .
Ankle Evertors ( ~ 1 ) .
2-5 Toe E x t e n s i o n (L5)
2-5 Toe F l e x i o n (L5)
G r e a t Toe E x t e n s i o n ( ~ 5 ) .
G r e a t Toe F l e x i o n (L5)
Mark on body c h a r t f o r numbness,
paresthesia, hypoesthesia,
r a d i a t i n g p a i n or o t h e r symptoms.
.....
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
..............
.....
......
....
......
.
....
Special Tests:
Ant Drawer
Lateral Stability
Ankle D o r s i f l e x i o n Test
R i g i d F l a t Feet Test
T i b i a i Torsion Test
Calcaneous Tap T e s t
T i b - F i b Compress-Proximal
-Distal
P a l p a t e Post-med T i b i a
.................
..........
....
.......
........
........
..
....
.....
-
+
or
+ or
-
t i g h t gastroc,
+ or + or
+ or
+ or
+ or
+ or
t i g h t soleus, o r
-
-
Comments :
P:
Short term goals:
Mid term goals :
Long t e r m goa 1 s :
Athletic T r a i n i n g
Evaluator
Date
--
P h y s i c a l Therapy
Evaluator
Date
P h y s i c i a n Review
Date
JOSPT MaylJune 1984
STANDARDIZED EVALUATION FORMS
Name :
SS#:
Last
First
M F
Classification
Impress ion
Intens i ty/Frequency/Durat ion
Treatment
Re-eva 1 Dates
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Comments
Fig. 1A
Name :
SS# :
Last
First
M F
Classification
Impress ion
Treatment
Intensity/Frequency~Duration
Re-eva l Dates
Comments
Fig. 2A
367
368
TOMBERLIN ET AL
SS#:
Name :
Last
First
M F
Class i f i c a t i o n
Impress ion
Intens i :y/Frequency/Duration
Treatment
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Re-eva l Dates
Fig. 3A
Name :
SS# :
Last
First
M F
Classification
Impress ion
Treatment
I n tens i ty/Frequency/Durat ion
Re-eva l Dates
Comments
Fig. 4A
JOSPT Vol. 5, No. 6
JOSPT MaylJune 1984
369
STANDARDIZED EVALUATION FORMS
Name :
SS#:
Last
First
.. .
Class i f i c a t i o n
Impress ion
I n t e n s i ty/Frequency/Duration
T rea tnen t
Re-eva 1 Dates
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Comrnen t s
Med
Ant
Lat
Fig. 5A
Name :
SS#:
Last
First
M F
Class i f i c a t i o n
impress i o n
Treatment
I n t e n s i ty/Frequency/Durat i o n
Re-eva 1 Dates
Comments
Fig. 6A
Pos t
370
TOMBERLIN E T AL
SS#:
Name :
Last
First
M F
Classification
Impress ion
Intensity/Frequency/Du~ation
Treatment
Ke-eva 1 Dates
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Conrnen t s
Fig. 7A
SS#:
Name :
Last
First
M F
Class i f i c a t i o n
Impress ion
Treatment
Intens i ty/Frequency/Durat ion
Re-eva 1 Dates
Fig. 8A
JOSPT Vol. 5, No. 6
JOSPT MaylJune 1984
STANDARDIZED EVALUATION FORMS
371
SS#:
Name :
Last
First
F
Class if ication
M
impress ion
Treatment
Intensity/Frequency/Duration
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Re-eva l Dates
Fig. 9A
trolling consistency is very important because of
-Manual Muscle T e ~ t ~ ~ ~ ~ l '
physical therapy and athletic training students and
-reflexes and sensationlo
-special tests for the specific body area3~9~12 interns that rotate through the Physical Therapy
Unit-Student Health Center, University of Wis-anthropometric measurement^'^^
consin-La Crosse. Because of the large volume
-space for comments
of patients we see, there is a need for reducing
The assessment section has space for a spethe amount of time needed in longhanding
cific written assessment of the injury.
The planning section is divided into short-term,
S.O.A.P. notes. The standardized evaluation
forms are an efficient alternative to the longhand
mid-term, and long-term goals. These should inS.O.A.P. note.
clude the overall goal, the treatment program
There is a continuing effort to revise and im(intensity, frequency, and duration), the type of
treatment, and the result expected. Treatment
prove this system.
flow sheets (see Figs. 1A through 9A) with body
charts are attached to the evaluation forms with
REFERENCES
specific orders for use by aides and physical
1. Arnheim DD, Klafs CE: Conditions of the knee: atrophy measurement. In: Modern Principles of Athletic Training, Ed 3, p 292. St.
therapy students and with the date of re-evaluaLouis: CV Mosby Co, 1973
tion to be done by the evaluating therapist.
2. BasmajianJV: Surface Anatomy: An Instruction Manual. Baltimore:
The patients (students) are directly referred by
Williams & Wilk~ns,1977
3. Birnbaum JS: The Musculo-Skeletal Manual. New York: Academic
physicians in the Student Health Center (or by
Press lnc, 1982
personal physicians that the patients have seen)
4. Cole TM, Tobis JS: Measurement of musculoskeletal function. In:
to physical therapy for evaluation and treatment
Kotke FJ, Stillwell GK, Lehman JF (eds). Krusen's Handbook of
Physical Medicine and Rehabilitation, Ed 3. Philadelphia:WB Saunprograms. The majority of patients we see have
ders Co, 1982
musculoskeletal disorders, i.e., acute ortho5. Daniels L, Worthingham C: Muscle Testing: Techniques of Manual
paedic, athletic injuries, and postsurgical patients.
Examination, Ed 3. Philadelphia: WB Saunders Co, 1972
We feel these evaluation forms allow us to
6. Esterson PS: Measurement of Ankle Joint Swelling Using a Figure
of 8. J Orthop Sports Phys Ther 151-52,1979
perform consistent and efficient patient evalua7. Gerhardt JJ: SFTR Recording of Joint Motion and Position in the
tions in a short amount of time, especially for
Neutral-Zero Method. Bess Kaiser Hospital-Permanante Clinic,
acute musculoskeletal injuries. A method of conPortland, OR, 1980
Journal of Orthopaedic & Sports Physical Therapy®
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Copyright © 1984 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
372
TOMBERLIN ET AL
8. Hill JR: The Problem-OrientedApproach to Physical Therapy Care.
Washington, DC: American Physical Therapy Association, 1977
9. Hoppenfelt S: Physical Examination of the Spine and Extremities.
New York: Prentlce-Hall Inc, 1976
10. Hoppenfeld S: Orthopaedic Neurology: A Diagnostic Guide to
Neurologic Levels. Philadelphia: JB Lippincott Co, 1977
11. Kendall HO, Kendall FP: Muscles: Testing and Function. Baltimore:
Williams & Wilkins, 1971
JOSPT Vol. 5, No. 6
12. Ramamurti CP, Tinker RV: Orthopaedics in Primary Care. Baltimore: Williams & Wilkins, 1979
13. Stolov WC: Evaluation of the patient. In: Kotke FJ, Stillwell GK,
Lehman JF (eds), Krusen's Handbook of Physical Medicine and
Rehabilitation, Ed 3. Philadelphia: WB Saunders Co, 1982