CASE:

SUBJECTIVE ASSESSMENT:
 NAME:
 AGE:
 GENDER:
 ADDRESS:
 Ph. No:
 OCCUPATION:
 CHIEF COMPLAINTS:

 HISTORY:
o PAST HISTORY:

o PRESENT HISTORY:

o PERSONAL HISTORY:

o FAMILY HISTORY:

o MEDICAL HISTORY:
 o SURGICAL HISTORY:

o PT HISTORY:

o SOCIOECONOMIC HISTORY:

OBJECTIVE ASSESSMENT:
 HAND DOMINANCE:
 Right
 Left

 VITALS:
 Temp:
 PR:
 BP:
 RR:

 OBSERVATION:
 Built of the patient:
 Position of the patient:
 Attitude of the limbs:

JOINT RIGHT LEFT

SHOULDER
ELBOW
WRIST
FINGERS
HIP
KNEE
ANKLE
SUBTALAR
 TOES

 Breathing pattern:
 Facial symmetry:

 Deformities:

 External appliances:

 Skin observation:

 Posture:

 Gait:

 PALPATION:

 EXAMINATION:
 Consciousness:

 Higher mental functions:

 Speech:
 Orientation:
 Memory:
 Intelligence:
 Behavior:
 Cranial Nerve Examination:

 I - Olfactory nerve:
 II - Optic nerve:
 III –Occulomotor nerve:
 IV - Trochlear nerve:
 V - Trigeminal nerve/dentist nerve:
 VI - Abducens nerve:
 VII - Facial nerve:
 VIII - Vestibulocochlear nerve/Auditory nerve:
 IX - Glossopharyngeal nerve:
 X - Vagus nerve:
 XI - Accessory nerve/Spinal accessory nerve:
 XII - Hypoglossal nerve:

 Sensory System Examination:

 Superficial senses:
 Touch:
 Pain:
 Temperature:
 Pressure:
 Deep senses:
 Vibration:
 Proprioception:
 Kinesthetic sensation:
 Cortical senses:
 Tactile localization:
 Tactile discrimination:
 Sterognosis:
 Graphesthesia:
 Double simultaneous sensation:
 Texture discrimination:

 Motor System Examination:

 Tone:
 Bulk:
 ROM:
 Strength:
  Limb length:

 Reflex System Examination:

 Superficial reflexes:
 Abdominal:
 Plantar:
 Corneal:
 Deep reflexes:
 Jaw jerk:
 Biceps jerk:
 Triceps jerk:
 Patellar jerk:
 Achillis tendon jerk:

 Posture:

 Balance:

 Coordination:

 Gait:

 ADL Examination:

INVESTIGATIONS:
PROBLEM LIST:

TREATMENT PLAN:

DAY WISE MANAGEMENT PROTOCOL: