Assessment Performa

Demographic data:
Name:
Age:
Gender:
Occupation:
Address:
Chief complaint:

History:
Present history:

Past history:
Medical history:
Surgical history:
Family history:
Personal history:
Pain history:
Onset:
Site:
Side:
Aggravating factor:
Relieving factor:
Type:
NPRS:

On examination
Range of motion:

Manual muscle testing:

Investigations -

Special test-  

Provisional diagnosis- 

Treatment-
Short term goal:

Long term goal:

Electrotherapy Modalities:

Exercise programme: 

Home Advice: