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Medical Record Number

Name
Age
Occupation
Hobbies

INJURY REHABILITATION REPORT

Visual Analogue Score (VAS) Range of Movement (ROM)


12 12
10 10
8 8
6 6
4 4
2 2
0 0
Sesi 1 Sesi 2 Sesi 3 Sesi 4 Sesi 5 Sesi 6 Sesi 1 Sesi 2 Sesi 3 Sesi 4 Sesi 5 Sesi 6

VAS ROM

FUNCTIONAL SCORE

PRE-TREATMENT POST-TREATMENT

Phase 1 Phase 2 Phase 3 Phase 4


1 2A 2B 3A 3B 4
Phases Sport
Basic Advanced
Inflammation Specific
Strengthening Strengthening
Skill
Goals  Pain  Initial/Partial  Pain Free  Muscle  Good  Good
Reduced Weight-  Full Strength  Jumping Sport
 Swelling bearing weight- >90% & Specific
Reduced  Full ROM bearing  Good Landing Skill
 ROM  Good Static  Ability to  Dynamic Posture  Special
Improved Posture & Slow Jog Movement  Good Test
Walking Gait  Good Stability Agility Passed
Balance  Balance  Good
 Good  Running Sprint
Functional Form
Posture

PT. WELSPRO INSPIRASI UTAMA


Giesmart Plaza (d/h Graha Anugerah) Mezzanine & 2nd Floor, Jl. Raya Pasar Minggu No.17A Pancoran, Jakarta Selatan 12780
DKI Jakarta E info@welspro.com W www.welspro.com P +6221-2696 66000
Medical Record Number
Name
Age
Occupation
Hobbies

SUMMARY

RECOMMENDATION

Jakarta, ____________________

___________________________

PT. WELSPRO INSPIRASI UTAMA


Giesmart Plaza (d/h Graha Anugerah) Mezzanine & 2nd Floor, Jl. Raya Pasar Minggu No.17A Pancoran, Jakarta Selatan 12780
DKI Jakarta E info@welspro.com W www.welspro.com P +6221-2696 66000

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