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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
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 Unit-
Student 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
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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.
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

The need for a consistent and efficient method The format of the forms is divided into four
of patient evaluation is not a new one. Standard- sections: subjective, objective, assessment, and
ized evaluation forms that include body charts can planning (S.0.A.P.).8,'3There are s'imilar features
be useful in recording subjective and objective to all the evaluation forms. The subjective section
data in a systematic way. At the Physical Therapy includes the following common items:
Unit-Student Health Center, University of Wis- -the mechanism of injury
Journal of Orthopaedic & Sports Physical Therapy

consin-La Crosse, we have designed and put into -previo~;s history of injury
use this type of evaluation form. -any pain, edema, numbness, or tingling pres-
We use a specific evaluation form depending ent now or at time of injury and have they
on the body area involved. Currently we have changed
divided the body into nine areas and have nine -did the patient hear or feel any sounds at
corresponding evaluation forms: Cervical Spine time of injury
(Fig. 1); Anterior Torso (Fig. 2); Lumbar Spine and -can patient ambulate now or at time of injury
Sacroiliac (Fig. 3); Distal Forearm, Wrist, Hand, without limp or pain (lower extremity injury)
Thumb, and Fingers (Fig. 4); Proximal Forearm Each objective section includes body charts to
and Elbow (Fig. 5); Shoulder (Fig. 6); Hip and mark findings of observation and palpation includ-
Thigh (Fig. 7); Knee (Fig. 8); Lower Leg, Ankle, ing any edema, deformity, discoloration, tender-
and Foot (Fig. 9). Evaluation forms specifically for ness, crepitus, etc., present. There is at least one
gait and posture are being compiled. (Currently body chart per form usually with the skeletal
there is not an evaluation form for the thoracic system outlined in the body part or area. Gener-
spine.) This list of evaluation forms is not neces- ally, the body charts include anterior, posterior,
sarily a complete one, and further subdivisions of medial, and lateral views. One set of body charts
the body areas may be needed. is for marking observation and palpation findings2
as previously mentioned, and another set is for
marking sensation test findings. The rest of the
Intern, Spring 1983, Mayo Foundation School of Allied Health Sci- objective section includes:
ences.
t Clinical Supervisors: Student Health Center-Physical Therapy Untt, -norms for AROM and pROM4 using the
University of Wisconsin-La Crosse, La Crosse, WI 54601. S.F.T.R. method of recording7
JOSPT MaylJune 1984 STANDARDIZED EVALUATION. FORMS 349

PIiYS I CAL THERAPY UEI I T Social Security # :


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 : -- P a i n f u l area: R or L or B or Center

Date o f i n j u r y : Date o f i n i t i a l evaluation-TR -PT :

S: 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 :
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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, Pain more severe? A.M. or P.M.

..........
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Dizziness Y or N \dhen?
Stiffness .......... Y or N Where?
....
rlumbness o r t i n a l i n a ? Y or N \/here7
\,leakness? ..........
d 2

Y or N Where?
Other medical problems? ... Y or N What?
Ned i c a t i o n s ? ........ Y or E.4 !,/hat?
Docs p a t i e n t use a p i l l o w ? . Y or N \./hat k i n d ? When?

Comments: '
Journal of Orthopaedic & Sports Physical Therapy

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 .

Special t e s t s :
Compression .... + or -
Distraction .... + or -
Valsalva . . . . . .+ or -
Swallowing.. . . .+ or -
Adson ....... + or -
TMJ P a l p a t i o n ... + or -
Fig. 1
JOSPT Vol. 5,No. 6

ROM: S 40-0-40 SENSORY: Mark on body c h a r t f o r numbness,


F 45-0-45 t i n g l i n g , p a r e s t h e s i a , hypoesthesia,
R 50-0-50 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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MMT :
..
D e l t o i d (C5, a x i l l a r y N)
REFLEXES :
(C5)-Biceps. ... = .,
Biceps ( ~ 5 , 6 , musculotaneous
..
W r i s t E x t (C6, r a d i a l N)
......
(Cb) - B r a c h i o r a d i a l i s =
(C7)-Triceps ... = .
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

F i n g e r F l e x (C8) (C8) +!one


F i n g e r Abd ( ~ 1 ) . ...... (TI ) -None
Journal of Orthopaedic & Sports Physical Therapy

P: 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
-
Date PhysicalTherapy
-
Date PhysicianReview
-
Date
Eva 1 ua t o r Eva 1 ua t o r
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS 351

PllYS i CAL THERAPY UNIT S o c i a l S e c u r i t y hi:


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 : - P a i n f u l area: R or L or B or Center

Date o f i n j u r y : Date o f i n ; t i ; l c v a i u ~ t i o n - TR: PT :

S: biechanism o f i n j u r y o r onset o f p a i n :

H i s t o r y o f p r e v i o u s problems: -
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Kind o f p a i n :

\./hat f' pain? \*ihct 6 pa i n ?


Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Consistant pain Y or N I n t e r m i t t e n t pain Y 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 , tenderness, c r e p i t u s , e t c . ,


Journal of Orthopaedic & Sports Physical Therapy

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
JOSPT Vol. 5, No. 6

0 : ROM:

MMT : Special t e s t s :
Upper r e c t u s abdominus S i t up
Lower r e c t u s abdominus Bilateral leg raise
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Ext o b l ique -Left


-Riaht
-
d ~

I n t oblique Left
-Right

Comment s :
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy

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 Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Eva 1 ua t o r Eva 1 ua t o r
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS

PHYSICAL THERAPY UNIT Social Security #:


Student H e a l t h Center
U n i v e r s i t y o f Wisconsin-La Crosse

LUIlBAR SPl NE AND SACRO- I L IAC EVALUAT 10'1 FOfil?

Name : P a i n f u l area: R or L or B or Center

Date o f i n j u r y : Date o f i n i t i a l e v a l u ~ t i o n - T R : PT :

S : Mechanism o f i n j u r y o r o n s e t o f p a i n :

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:
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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 or N -
sittinq? Y or N - - prone? Y or N
-supine? Y or N -
other?
-coughing? Y or N -
b e a r i n g down? Y o r N - other?
P a t i e n t has p a i n c o n s t a n t l y o r intermittently?
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

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 or N What?
P a t i e n t on m e d i c a t i o n ? Y or N What?
P a t i e n t n o t i c e d any weakness? Y or N Numbness? Y or No Tingling? Y or N
What i s c o n d i t i o n o f p a t i e n t ' s bed?

Observe and p a l p a t e f o r s w e l l i n g , Sensory:


Journal of Orthopaedic & Sports Physical Therapy

d e f o r m i t y , d i s c o l o r a t i o n , tender- Mark on body c h a r t f o r numb-


ness, c r e p i t u s , e t c . , and mark on ness, t i n g l i n g , p a r e s t h e s i a ,
body c h a r t . 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: Reflexes:
S 30-0-85 ( ~ 4 )Knee j e r k = , R>L , L7R
F 30-0-30 ( ~ 1 )Ankle j e r k a , R ? L , L?R
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) ..
Special t e s t s : 1
Hoover t e s t ................ + or - Supine/Long s i t t i n g test... + or -
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Supine-chin t o c h e s t ....... + or - Sacral push-cranial ........ + or -


Raise b o t h legs s t r a i g h t 2". + or - -caudal......... + or -
V a l s a l v a Maneuver........... + or - ........ +
P a l p a t i o n o f Sacrum or -
S 1 Compression .............. + or - I l i a c Rot-ant .............. + or -
S 1 Distraction.............. + or - -p ost.............
Gaenslin test............... + . or - Hip adduction/flexion ...... + or -
............. + - .... + .
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Patrick's test or Check PSIS-raise L l e g or


Rectus abdominus.... ........ + or - .... +
-raise R leg or -
..... +
- f l e x trunk or -
Comments :
Journal of Orthopaedic & Sports Physical Therapy

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 Date PhysicalTIierapy Date PhysicianReview Date
Eva 1ua t o r Eva 1ua t o r
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS

PHYSICAL THERAPY UNIT Social Security # :


Student H e a l t h Center
Un i v e r s i t y o f \.lisconsin-La Crosse

HAND, WRIST, FOREARM, THUMB, AND FINGERS EVALUATION

Name : - Affected side; R or L

Date o f i n j u r y : Date o f i n i t i a l evaluation-TR: -PT :

S: 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 :
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Has p a t i e n t f e l t o r heard any sounds?. . .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?

Has p a t i e n t f e l t any weakness? . . . . . .Y or N When?


Where?
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

When does p a t i e n t have p a i n ? What k i n d ?

Where i s p a i n ?

What makes p a i n change?


Journal of Orthopaedic & Sports Physical Therapy

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 ion, tenderness, c r e p i tus,


e t c . , and mark on body c h a r t .

Palpation:

Fig. 4
356 TOMBERLIN ET AL JOSPT Vol. 5, No. 6

0: ROM: Norma 1 Active Pass i v e


Wrist S D - 60
F 20-0- 30
F i n g e r (11P) S 45-0- 90
(PIP) S 0-0-100
(DIP) S 10-0-90
Thumb ( I P) F 10-0- 80
(Mp) F 0-0-50
(CM) F 0 - 0 - 15

MMT : W
-- r i s t Finger -
--- Thumb
Flexion ..... F l e x NCP.. F l e x I1CP..
Extension. ... Ext FICP .. .
..--
Ext MCP..
Ulnar deviation . F l e x PIP.. Flcx !?.
Radial d e v i a t i o n . Ext PIP ..-- E x t 1P ....
Supination. ... F l e x DIP.. Abd C:1C. ..
..... Ext DIP .
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Pronation Add CMC.. -


abd !<CP Oppos i t i o n
add MCP

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,
Special t e s t s :
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

r a d i a t i n g p a i n o r o t h e r symptoms.
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) + or -
F l e x o r d i g i t o r u m profundus t e s t (DIP) ..... + or -
I n t r i n s i c muscle t i g h t n e s s test........... + or -
Retinaculum t i g h t n e s s test................ + or -
Ulnar 6 Radial a r t e r y supply t e s t ......... + or -
D i g i t a l a r t e r y supply t e s t . . .............. + or -
Radial pulse .............................. = or R?L
or L)R

Comments :
Journal of Orthopaedic & Sports Physical Therapy

-- -

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 Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Eva 1 ua t o r Eva l ua t o r
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS

PHYSICAL THERAPY UNIT S o c i a l S e c u r i t y #:


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

Name : Affected side: R or L or B

Date o f i n j u r y : Date o f i n i t i a l evaluation-TR: -PT:

S: 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 :

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?

Does p a t i e n t f e e l any numbness o r t i n g l i n g ? . Y or N When?


Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

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?

Does elbow f e e l s w o l l e n ? . .......... Y or N

Has s w e l l i n g changed? .............Y or N


Does p a t i e n t have any weakness? ............... Y or N..Where?
Comments :
Journal of Orthopaedic & Sports Physical Therapy

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 La t Ant Post

Pal p a t ion:

ROM: Normal Active Passive


S 0-0-150
R 90-0- 80
Fig. 5
TOMBERLIN ET AL JOSPT Vol. 5, No. 6

HMT : Neurological :
F l e x i o n (C5,6) ... Reflexes-
E x t e n s i o n (C7)... B i c e p s (C5) .......
.
S u p i n a t i o n (C5,6). Bracioradialis ( ~ 6 ) ...
P r o n a t i o n (C6,8-TI) . T r i c e p s (C7). ......
Special t e s t s : Sensory: H a r k on body c h a r t f o r numbness, t i n g -
Valgus s t r e s s . . . . .+ or - 1 ing, paresthesia, hypoesthesia, hyperesthesia,
Varus s t r e s s..... + or - 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.
Tinel sign ...... + or -
Tennis elbow t e s t . . . + or -
Compress u l n a & r a d i u s . + or -
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Comments :
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy

P: Short term goals:

- - ---

Mid term goals:

Long t e r m goa 1 s :

-- -
Athletic Training Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Eva1 u a t o r Evaluator
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS

PttYS I CAL THERAPY UNIT Social Security #:


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: R or L

Date o f i n j u r y : Date o f i n i t i a l evaluation-TR: -PT :

S: 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 :
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Did p a t i e n t hear o r f e e l any sound?. Y or N When?

Does p a i n change7 ......... Y or N When?

Can p a t i e n t l i e on t h a t s i d e ? ... Y or N
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

I s the shoulder swollen? ......Y or N


Any change? ............ Y or N 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 , tenderness, crepitus,


Journal of Orthopaedic & Sports Physical Therapy

e t c . , and mark on body c h a r t .

Palpation:

~ - -
- - ~

ROM: Normal Active Passive


S 50-0-170

Fig. 6
JOSPT Vol. 5, No. 6

IlMT : Neurological :
Flexion ( ~ 5 , 6 ) ........... Reflexes -
Biceps (C5) .= , R) L
Extens i o n (C5,6,7,8) ........ L7R
A b d u c t i o n (C5,6) .......... - Brachioradialis ( ~ 6 ) .
......
Adduct i o n ( ~ 5 , 6 , 7 , 8 - T I ) . = , R7L. L 7 R
E x t . Rot. (C5.6) .......... -Triceps (C7) .....
I n t . Rot. (C5,6,7,8-TI). ...... = , R)L, L7R
Scapular e l e v a t i o n (C3,4,5)..... Sensory: Mark on body c h a r t f o r
Scapular r e t r a c t i o n (C5) ...... numbness, t i n g l i n g , p a r e s t h e s i a ,
...
Shoulder p r o t r a c t i o n (C5,6,7). hypoesthesia, hyperesthesia,
Horizontal Abduction ....... r a d i a t i n g p a i n o r o t h e r symptoms.
H o r i z o n t a l Adduction ........
Special t e s t s :
Yergason t e s t .......... + or -
Drop arm t e s t ...,.......+ or -
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........ +
Apprehension t e s t or -
.......... +
A-C t r a c t i o n or -
.... +
C l a v i c ! e movement a t A-C. or -
. +
lmpingment ( l n t . Rot. & F l e x . ) . or -
Quadrant.. .......... + or -
Locking ..............+ or -
...... +
E i c i p i t a l tendon t e s t or -
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Comments :
Journal of Orthopaedic & Sports Physical Therapy

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 Date P h y s i c a l Therapy Date P h y s i c i a n Review Date


Eva 1 u a t o r Eva 1 u a t o r
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS

PHYSICAL THERAPY U N I T S o c i a l S e c u r i t y #:
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 THIGH EVALUATION FORM


Name : Affected side: R or L or B

Date o f i n j u r y : Date o f i n i t i a l e v a l u a t i o n - TR PT

S: 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 :
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Does p a t i e n t f e e l p a i n ? Y or N Where?
What k i nd?
How lono?.,
What causes change?
Doespatientfeelswelling? Y or N Where?

Comments :
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

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 .
Journal of Orthopaedic & Sports Physical Therapy

Pal p a t i o n :

Fig. 7
362 TOMBERLIN ET AL JOSPT Vol. 5. No. 6

0: ROM: -Normal
-- Active Passive
S 15-0-125 -
F (so) 45-0- 15
T(S90) 45-0- 20
R(SO) 45-0- 40
R (S90) 45-0- 45
MI1T :
MI1T -SEi<SC)RV
-- :
..
F l e x o r s ( L 1 ,2,3) Mark on body b o d ~c h a r t f o r numbness,
nu1nbness, t i n g l j n g ,
Extensors(S1) ... 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
Abductors(L5) ... - o t h e r symptoms.
Adductors ( ~ 2 , 3 , 4 ). -
Ext. Rotators ...
I n t . Rotators ...
Special t e s t s :
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SLR . . . . . . . . . . . . . . + or -
Trendelenburg . . . . . . . . .+ or -
. . + or -
I l i o - t i b i a 1 band t i g h t n e s s
Hip flexion tightness . . . . . + or -
Patrick's test . . . . . . . . + or -
. . : + or -
Compress i o n ( l n t Rot & Add)
. . + or -
( E x t Rot & Add).
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

. . . . apparent
Leg l e n g t h d i s c r e p e n c y + or true + or -
@ 0
Comments :
Journal of Orthopaedic & Sports Physical Therapy

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 Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Evaluator Eva 1ua t o r
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS 363

PHYSICAL THERAPY UNIT S o c i a l S e c u r i t y #:


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: R or L or B

Date o f i n j u r y : Date o f i n i t i a l e v a l u a t i o n - TR PT

S: 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 :
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pp -

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?


Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

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 .
Journal of Orthopaedic & Sports Physical Therapy

Observe g a i t: -

Palpation:

Fig. 8
364 TOMBERLIN ET AL JOSPT Vol. 5, No. 6

0: ROM: Normal (S) 0-0-130 R Active -0 - R Passive


L Active -0 - L Passive- --0-O ----
Anthropometric: j t l i n e 2 " a b o v e j t l i n e 6"abovejtline
(5cm) (1 5cm)

Knee j e r k r e f l e x = , R 7 L, LrR Sensory: Mark on body c h a r t f o r numbness, t i n g l i n g ,


paresthesia, hypoesthesia, hyperesthesia,
MMT : . a i no r o t h e r svmotoms.
r a d i a t i n q. ~
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)
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Attach o r t h o t r o n evaluation sheet.

Special t e s t s :
Lachman's ............ + or .
...
Valgus S t r e s s ( f u l l e x t ) . ..+ of - (20) f l e x . . . . . .+ or -
.....
Varus s t r e s s ( f u l l e x t ) + or - ( 2 0 ~ )f l e x ) . . . . . .+ or -
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Drawer ( a n t ) .......... + or - (Post) . . . . . . . .+ or -


...
Slocum's R o t a r y ( i n t r o t ) . + or - (ext r o t ) . . . . . . .+ or -
Apley (comp) .......... + or - (dis t) . . . . . . . .+ or .
Bounce home .......... . + or -
Apprehension ..........
.
1 . l ~H u r r a y (Valgus w i t h e x t r o t ) +
+
or
or
-
-
(Varus w i t h i n t . rot.). + or -
........
P a t e l l a r Grinding + or .
P a t e l l a r Ballotment
Chondromalacia t e s t s
. .. .. .. .. .. ..
+
+
or
or
.
-
Comments :
Journal of Orthopaedic & Sports Physical Therapy

P: 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 Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Eva 1 ua t o r Evaluator
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS

PIIYS I CAL THERAPY UNIT S o c i a l S e c u r i t y #:


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

FOOT, ANKLE, AND LOWER LEG EVALUATION FORM

Name : Affected side: R or L or B


Date o f i n j u r y : Date o f i n i t i a l e v a l u a t i o n - T R : -PT:

S: 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 :

D i d p a t i e n t hear or f e e l any sound? ..... Y or N What?


Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

When?

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 ? Y or N..at t i m e o f i n j u r y ? Y or N
...
w i t h o u t 1 imp? Y or N..at t i m e o f i n j u r y ? Y or N
...
without pain? Y or N..at t i m e o f i n j u r y ? Y or N
i s the ankle swollcn? .................... Y or El
Has t h e s w e l l i n g changed? ................ Y or N..How?
Journal of Orthopaedic & Sports Physical Therapy

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, crepi tus,


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 =
', R>L,
L>R
L>R
0
-Posterior Tibia1 = , R)L, L)R
TOMBERLIN ET AL JOSPT Vol. 5. No. 6

0: ROM:
Ankle ................... -
A c t-
ive Passive

Hind Foot... ............


Fore Foot ...............
...............
G r e a t Toe (MP) ..........
( I?). .........
2nd t o 5 t h Toes (HP) ....
Which Toe? (PIP) .....
(DIP) .....
MMT :
T r i c e p s Surae ( ~ ,1 2)...... --
SENSORY:
tingling,
Mark on body c h a r t f o r numbness,
paresthesia, hypoesthesia,
T i b Ant ( ~ 4 ) .............. r a d i a t i n g p a i n or o t h e r symptoms.
.....
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) ....
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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) ....
Special Tests:
Ant Drawer ................. + or -
Lateral Stability .......... + or -
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

....
Ankle D o r s i f l e x i o n Test t i g h t gastroc, t i g h t soleus, o r -
R i g i d F l a t Feet Test....... + or -
T i b i a i Torsion Test ........ + or -
Calcaneous Tap T e s t ........ + or -
T i b - F i b Compress-Proximal .. + or -
....
-Distal + or -
.....
P a l p a t e Post-med T i b i a + or -
Comments :
Journal of Orthopaedic & Sports Physical Therapy

P: Short term goals:

Mid term goals :

Long t e r m goa 1 s :

--
Athletic T r a i n i n g Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Evaluator Evaluator
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS 367
Name : SS#:
Last First

M F
Impress ion Classification

Treatment Intens i ty/Frequency/Durat ion

Re-eva 1 Dates

Comments
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Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Fig. 1A

Name : SS# :
Journal of Orthopaedic & Sports Physical Therapy

Last First

M F
Impress ion Classification

Treatment Intensity/Frequency~Duration

Re-eva l Dates

Comments

Fig. 2A
368 TOMBERLIN ET AL JOSPT Vol. 5, No. 6
Name : SS#:
Last First

M F
Impress ion Class i f i c a t i o n

Treatment Intens i :y/Frequency/Duration

Re-eva l Dates
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Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Fig. 3A

Name : SS# :
Last First
Journal of Orthopaedic & Sports Physical Therapy

M F
Impress ion Classification

Treatment I n tens i ty/Frequency/Durat ion

Re-eva l Dates

Comments

Fig. 4A
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS 369
Name : SS#:
Last First

.. .
Impress ion Class i f i c a t i o n

T rea tnen t I n t e n s i ty/Frequency/Duration

Re-eva 1 Dates

Comrnen t s
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Med Lat Ant Pos t


Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Fig. 5A

Name : SS#:
Last First
Journal of Orthopaedic & Sports Physical Therapy

M F
impress i o n Class i f i c a t i o n

Treatment I n t e n s i ty/Frequency/Durat i o n

Re-eva 1 Dates

Comments

Fig. 6A
370 TOMBERLIN E T AL JOSPT Vol. 5, No. 6
Name : SS#:
Last First

M F
Impress ion Classification

Treatment Intensity/Frequency/Du~ation

Ke-eva 1 Dates

Conrnen t s
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Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Fig. 7A

Name : SS#:
Last First
Journal of Orthopaedic & Sports Physical Therapy

M F
Impress ion Class i f i c a t i o n

Treatment Intens i ty/Frequency/Durat ion

Re-eva 1 Dates

Fig. 8A
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS 371
Name : SS#:
Last First

M F
impress ion Class if ication

Treatment Intensity/Frequency/Duration

Re-eva l Dates
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Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Fig. 9A

-Manual Muscle T e ~ t ~ ~ ~ ~ l ' trolling consistency is very important because of


-reflexes and sensationlo physical therapy and athletic training students and
-special tests for the specific body area3~9~12 interns that rotate through the Physical Therapy
-anthropometric measurement^'^^ Unit-Student Health Center, University of Wis-
-space for comments consin-La Crosse. Because of the large volume
Journal of Orthopaedic & Sports Physical Therapy

The assessment section has space for a spe- of patients we see, there is a need for reducing
cific written assessment of the injury. the amount of time needed in longhanding
The planning section is divided into short-term, S.O.A.P. notes. The standardized evaluation
mid-term, and long-term goals. These should in- forms are an efficient alternative to the longhand
clude the overall goal, the treatment program S.O.A.P. note.
(intensity, frequency, and duration), the type of There is a continuing effort to revise and im-
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 measure-
therapy students and with the date of re-evalua- ment. In: Modern Principles of Athletic Training, Ed 3, p 292. St.
tion to be done by the evaluating therapist. Louis: CV Mosby Co, 1973
2. BasmajianJV: Surface Anatomy: An Instruction Manual. Baltimore:
The patients (students) are directly referred by Williams & Wilk~ns,1977
physicians in the Student Health Center (or by 3. Birnbaum JS: The Musculo-Skeletal Manual. New York: Academic
personal physicians that the patients have seen) Press lnc, 1982
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
programs. The majority of patients we see have Physical Medicine and Rehabilitation, Ed 3. Philadelphia:WB Saun-
musculoskeletal disorders, i.e., acute ortho- ders Co, 1982
5. 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
perform consistent and efficient patient evalua- of 8. J Orthop Sports Phys Ther 151-52,1979
7. 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 con- Portland, OR, 1980
Downloaded from www.jospt.org at on February 17, 2017. For personal use only. No other uses without permission.
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

372 TOMBERLIN ET AL JOSPT Vol. 5, No. 6


8. Hill JR: The Problem-OrientedApproach to Physical Therapy Care. 12. Ramamurti CP, Tinker RV: Orthopaedics in Primary Care. Balti-
Washington, DC: American Physical Therapy Association, 1977 more: Williams & Wilkins, 1979
9. Hoppenfelt S: Physical Examination of the Spine and Extremities. 13. Stolov WC: Evaluation of the patient. In: Kotke FJ, Stillwell GK,
New York: Prentlce-Hall Inc, 1976 Lehman JF (eds), Krusen's Handbook of Physical Medicine and
10. Hoppenfeld S: Orthopaedic Neurology: A Diagnostic Guide to Rehabilitation, Ed 3. Philadelphia: WB Saunders Co, 1982
Neurologic Levels. Philadelphia: JB Lippincott Co, 1977
11. Kendall HO, Kendall FP: Muscles: Testing and Function. Baltimore:
Williams & Wilkins, 1971
Journal of Orthopaedic & Sports Physical Therapy