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PHYSIOTHERAPY REPORT FORM

Patient Name: / CK / Date of Birth: / 02/05/75
Claim Number: / abc123 / Adjuster: / Don Smith
Date of Injury: / 11/5/2005 / Physician: / Dr. Proactive
Occupation: / seamstress / Vocational Status: / Working Full Hours/DutiesNot WorkingWorking Part Hours/DutiesHomemakerStudent
Referring Diagnosis: / cervical strain Grade II WAD, right elbow sprain
ASSESS DATE: Nov. 8, 2005 / RE-ASSESS DATE:

SUBJECTIVE REPORT

(relevant history and reported symptoms)

AT ASSESSMENT

/

AT RE-ASSESSMENT

constant moderate posterior cervical pain worsened with sustained postures (cooking) or repetitive use of arms (dusting, stirring, chopping)
constant moderate right elbow ache, throbbing

OUTCOME MEASURES

(2 measures recommended)
AT ASSESSMENT / AT RE-ASSESSMENT
Type of Measure / Score / Type of Measure / Score
Visual Analogue Pain ScaleNeck Disability IndexRoland Morris (Low Back)D.A.S.H. (Upper Extremity)L.E.F.S. (Lower Extremity) / 5 / Visual Analogue Pain ScaleNeck Disability IndexRoland Morris (Low Back)D.A.S.H. (Upper Extremity)L.E.F.S. (Lower Extremity)
Visual Analogue Pain ScaleNeck Disability IndexRoland Morris (Low Back)D.A.S.H. (Upper Extremity)L.E.F.S. (Lower Extremity)
DASH
NDI / 5
50%
25 / Visual Analogue Pain ScaleNeck Disability IndexRoland Morris (Low Back)D.A.S.H. (Upper Extremity)L.E.F.S. (Lower Extremity)
Comments: / Comments:

OBJECTIVE CLINICAL FINDINGS

(Observation, Range of Motion, Muscle Function, Palpation, Joint Mobility, Neurological Scan, Special Tests)
AT ASSESSMENT / AT RE-ASSESSMENT
Cervical:moderate limitation ROM flexion, lateral flexion,rotationlimited by muscle stretch
extension full, muscular pain
Marked incrrease upper trapezius tension with use of upper extremities
Elbow:R active and passive extension minus 15 degrees
flexion 80 degrees
ASSESS DATE: / RE-ASSESS DATE:

FUNCTIONAL ABILITY

(Work and / or Home Activities)
AT ASSESSMENT / AT RE-ASSESSMENT
waking 3-4 x per night due to pain, difficulty with housework
not able to work, perform heavy housework (mopping, vacuuming, scrubbing tub,floors)

FACTORS INFLUENCING RECOVERY

(i.e. other medical issues, complicating factors)
AT ASSESSMENT / AT RE-ASSESSMENT
job requires sustained postures and repetitive movements- no light or modified duties or hours available

TREATMENT PLAN AND RECOMMENDATIONS

(Specific Treatment Plan and Timeline)
AT ASSESSMENT / AT RE-ASSESSMENT
3 weeks - reduce pain, restore ROM - no pain at rest, improve activity level at home,
Begin GRTW –see attached for schedule
Physiotherapist: / I M Fantastic / Physiotherapist:
MSP Billing # / 11111111 / MSP Billing #
Clinic Name
Address / Superior Physiotherapy Inc
601 Smith Street
Physioland, BC / Clinic Name
Address
Date: / 11/8/05 / Date:
Copy to: / Dr. Proactive / Copy to: