KNEE EVALUATION
Name of Patient: ______
MD: ______
Date of Injury: ______
Date of Surgery: ______
Occupation: ______
Sports/Hobbies: ______
Date: ______
Diagnosis: ______
SUGAR LAND/STAFFORD GRAND PARKWAY/KATY WILLOW BROOK
711 AVENUE E 7830 W GRAND PKWY S 12539 PERRY RD
STAFFORD, TX 77477 RICHMOND, TX 77406 HOUSTON, TX 77070
SUBJECTIVE
Mechanism of Injury: ______
______
Diagnostics: ______
Prior Level of Function: ______
Current Functional Limitations:
Sitting Standing Driving Participate in prior sports
Walking SitàStand Prolonged Sit/Stand/Walking Up/Down Stairs
Pain Location: ______Pain Rating: __ Best __ Worse __ Average
Radiating Pain: __ No __ Yes ______
OBJECTIVE
WB Status: ______AD/Brace: ______
Gait: ______Palpation: ______
AROM STRENGTH SPECIALTY TESTS
R L R L + - + -
Flexion ______Lachman’s: Valgus Stress:
Extension ______Anterior Drawer: Varus Stress:
Hip Flexion ______Posterior Drawer: Lateral Pat Tilt/Glide:
Hip Extension ______McMurrary’s:
Hip Abduction ______
Hip Adduction ______
Assessment:
Current Problems:
Decreased ROM Joint Hypomobility Swelling
Decreased Strength Joint Hypermobility Gait Abnormalities
Decreased NM Control Soft Tissue Dysfunction
Balance Deficits Muscle Atrophy
Other: ______
Goals
↑ Knee ROM ___ degrees each plane to (I) sitàstand and negotiate uneven surfaces wo subjectives c/o’s
↑ Knee strength ___ grade to (I) amb at work, grocery store, uneven surfaces wo subjective c/o’s
↑ WB status to FWB without assistive device or subjective c/o’s
↑ Tolerance to PLOF, return to 100% PLOF – sports, recreational activities w no subjective c/o’s.
Other: ______
Rehab Potential: Excellent Good Fair Poor Discussed w/ pt goals/diagnosis/prognosis: Y N
TREAMENT PLAN:
TREATMENT FREQUENCY: ____ TIMES/WK FOR ____ WEEKS
Therapeutic Exercise Neuromuscular Re-ed
Modalities Gait Training
Manual Techniques (Mobes, MFR) Home Exercise Program
Traction (Manual / Mechanical) Other: ______
______
Susana Delgado, PT, DPT Doctor Signature / Date
SUGAR LAND/STAFFORD GRAND PARKWAY/KATY WILLOW BROOK
711 AVENUE E 7830 W GRAND PKWY S 12539 PERRY RD
STAFFORD, TX 77477 RICHMOND, TX 77406 HOUSTON, TX 77070