Department of Physiotherapy Cancer Rehabilitation Physiotherapy Assessment Form Name of the patient: VIVU . & x Ags 97% Occupation: Fares Height: 176 om Weight: 1) keg Date of admission: 18 3-24. ‘Type of Referral: Pre-Rehabiltation/ Post Rekabilitation D Peete 19-324 ie a fi repeat: Sprsmin all co- D Bruusl Dundig [em © Stage lac Chemotherapy Radiation 7 | Paliaive care] Cancer: therapy | eee Blower. [eds 66 Sy [30% f Pongal By 00 lil dom, G4 h fra) Diagnostic Tests: fa 1-2 ti shypeleolngy, -» C4] 4/14) + © gem- dyaromiing al G. “M39Present Medical Conatton echo Ves i portly mua il a rath Bek, has An Sy Pg a7, avn © 4% 8) Hay 21D ion in Omul anene stel oag Hh, mom adiabin, A), aggrev obtiy fasting | poh Nos tei AF tos he 4 pte TL 2 tempest. Gh 4 © Beconl Mrasa ge rm : WLE+ © coun + seers Es eg so gh Pcl” Lola eS cmangh wal eT 14 sca ie nan ach a ve Te Wp wabichim Yom faing repo gor pogo fo ast Medic! Histor faa 24 Pen sige LAF hy as bla totale PTL i Heat cote av a = rfefo~ ae Din] a ea ya bom Py bpidemin i ay coy “I Senn lb ps ye Ae Tie Pte Socio econom Family Histor Bee - On Retwas thin 4 1-9-9 aafaometvy oaherbeen” BE his a dente tatlont ea pet vy Jaslows For Iy C fata) Emotional Status: feu! games tie buy 4 wer creatonal story: Led A engaye tm cmd Kealeeds wits prends itals: (ow 1-4 ~24) zs RR BP Temperature | SPO2 130) orm TES as]. Fa bpm | a1 brpm estates Lt - Ahlen - Apoud, poirot istory of falls 712 sxercise habits: tages of Exercise: Tick the following ‘Contemplation Precontemplation Preparation | Action Maintenance Tobacco haaeiing i fTntensity— > Low > Moderate > High Progression eaped™ Respiratory Assessment:Motor assesse srmotion (ROM) Range o ] AROM | 9) ROM | Unmet Cin [Re pac Shoulder: Lat. ration Flexion Flexion | Extension Extension Abduction | Abduction Adduction ‘Adduction Ext. Rotation Int Rotation Extension, Supination tion Tau = Lip ruaion 7, $4 Tropie Skin changes: itany Or. Odterrapen, —5 Gilley SRE are Hand Grip:Girth: 2 sele Kent) ee Mid Trapezius — i Pi | aaa el es ealiakt "1 4-5-6 son a pose cece cere we = a pcs Education Asses Bees Basan es || AN py salt Eat Rotten 56 a laa a eet err aa s zy oe =e os ‘Pronation ‘Pronators CorF { See Mriatee | tec matane [cra | | Fie capiUnas | cami 1] ‘Extension Extensor Carpi Radialis Longus co | 3. Extensor Carpi Ulnaris C6 \ Flexor Digitorum Profundus Fes Seen. Sic, ie com i FieerDistonn swperteaie | crori_ | BES in MCP Roxon eT SSS ee J eee —_| Aesesog F ae aoe acim 8 Pollicis Longus ae aeLimb length: [= Right Gm) Teer | Th | ee \ Education Assessments PE informed alvat the con djhen aml Aeolleen ny treatrurd elect the coned » He vomnoskidl (i willy hr the ts obtunlpy re Hight Upper Limb Fatigue: FATIGUE SEVERITY SCALE (FSS) Pease circle the number between 1 and 7 which you feel best fits the following statement, This refers to your usual way of lite within the last week. 1 indicates “strongly disagree” ang 7 indicates “strongly agree Read and circle a number as Respene | My motivation is lower when Tam fatigued 12 G45 6a | Exercise brings on my fatigue O23 45 67 Tam easily fatigued fs ©2934 5 67 Fatigue interferes with my physical functioning 1n@304u 56s Fatigue causes frequent problems for me. O23 45 67 My fatigue prevents sustained physical fusetioning |) 23475 76 77 [Fatigue interferes with carrying out certain duis and|Q) 23 48767 responsibilities. Fatigue is among my most disabling symptoms. © 23-45 nea Fatigue interferes wih my work, family or social fe [2348 VISUAL ANALOGUE FATIGUE SCALE (VAFS) — on (/—4 4) STime "Please mark an “X” on the number line which describes your global fatigue with 0 being wort rl and 10 being normal. roblesTwas aware ofthe ation of my heart in ie abso fae a on ; Sense of hear ite increas, heat mings ran 2U(@) [Wl seed witoatany geod ene 3 lta ie was meaningless Seer eat Exercise Tolerance | 6-minute walk test Meal eee oa Max RPE: AQ Ses, Distance: 4 50m ‘5 Times sit to stand = Reduud mou, Prrtng- leak 5 Ba ~ Lye shanti, Loning obbadi on Se rae erie a F Parn~ L- fyreninn . MR39- Aelaul Atuyh- Our : Bele el sp orane,Home Program: ass Name &Signature of the Therapist Follow up Pian of treatment ~ Bhroobhy Drei an, re pa wijog Kon oD)