CLINICAL LOG BOOK

SUPERVISED CLINICAL PRACTICE-II

DPT-6 TH SEMESTER

NAME:
ROLL NO.

College of Physical Therapy

GC University Faisalabad
 Supervised Clinical Practice-II
6 th Semester DPT

Name: S/O, D/O, W/O:

Age: Gender: Male/Female

Marital status: Single □ Marred □ Language:

Occupation:

Address:

Mode of Admission:

Time of Admission:

Presenting Complaint:

HOPC:

___________________________________________________________________________
__________________________________________________________________________

 Location of Pain:
 Type of pain:
 On set of Pain
 Intensity of Pain: Mild □ Moderate □ Severe □
 Aggravating factors:
 Relieving factors:

Past Medical History:

 Hosp. Admissions:

 Blood Transfusion:

 Surgical History:
Medical history:

Asthma Yes/No Hypertension Yes/No Diabetes Yes/No

Tuberculosis Yes/No Hepatitis Yes/No Jaundice Yes/No
Fracture Yes/No Cardiac Disease/MI Yes/No Renal Disease Yes/No
Stroke Yes/No Heart Disease Ulcers Yes/No Carcinoma Yes/No
Osteoporosis Yes/No Hemophilia Yes/No Epilepsy/Seizures Yes/No
Others _________________

Allergies: ____________________________________________

Medications

___________________________________________________________________________

Treatment History:
___________________________________________________________________________
__________________________________________________________________________

Family History:

Parents: Dead/ Alive _____________________________________________________

No. of Siblings: _________________________________________________________
Heredity diseases:
Asthma Yes/No ____________________________________________
Hypertension Yes/No ____________________________________________
Diabetes Yes/No ____________________________________________
Tuberculosis Yes/No ____________________________________________
Hepatitis Yes/No ____________________________________________
Epilepsy/Seizures Yes/No ____________________________________________
Cardiac Disease/MI Yes/No ____________________________________________
Renal Disease Yes/No ____________________________________________
Stroke Yes/No ____________________________________________
Heart Disease Ulcers Yes/No ____________________________________________
Carcinoma Yes/No ____________________________________________
Osteoporosis Yes/No ____________________________________________
Hemophilia Yes/No ____________________________________________
Others ____________________________________________________________________

Socioeconomic History:

Social/health habits: -

Present and pre-morbid functional status/activity: -

Living environment: -
Growth and development history: -

General Health Status:

 Level of Awareness:________________________________________________
 Facial Expressions:_________________________________________________
 Body Type:_______________________________________________________
 BP( ) Pulse( ) Temperature( ) RR( )
 Anemia (Yes/No) Jaundice (Yes/No) Clubbing (Yes/No)
Cyanosis (Yes/No)
 Lymph Nodes:
Mastoid Yes/No _________________________________
Mandibular Yes/No ________________________________
Cervical Yes/No ________________________________
 Thyroid:

Labs:
Blood CP Yes/No S. Electrolyte Yes/No
Urine RE Yes/No S. Calcium Yes/No
RFTs Yes/No S. Urea
Yes/No
LFTs Yes/No S. Creatinine Yes/No
TFTs Yes/No S. Amilase Yes/No
BSR Yes/No S. Cholesterol Yes/No
BSF Yes/No BT.CT Yes/No
Cardiac Enzyme Yes/No Prothrombin time Yes/No
HCV Yes/No HIV Yes/No
ECG Yes/No

Imaging:
X-Ray Injured Limb (AP/Lateral View) Yes/No
X-ray Chest (AP view) Yes/No
Others

Consultations:

Documentation: