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Physical Therapy Assessment Form: Right Shoulder Pain

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Sen Per
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78 views

Physical Therapy Assessment Form: Right Shoulder Pain

Uploaded by

Sen Per
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NAME: _____Leslie D________________

PHYSICAL THERAPY DOB: (yy/mm/dd) _________________


ASSESSMENT FORM PHONE NUMBER: ___________________(home)
___________________(work)
Diagnosis: ____________________________________

Current History:

 pain x 4 weeks
 no MOI
 started playing tennis 3 months ago

Present Symptoms:
right shoulder pain
Aggravated by:
arm activity
Eased by:
not using arm
Pain Rating:
24 Hours
A.M.:
P.M. (sleeping posture): sleep (L) side
Day:

Irritability: ___ Non___ Mild___ Moderate___ Severe___ Key: Pain __X__ Numbness ___ Pins & Needles___

Past History/Past Treatment: Medications: (symptom control, GH, supplements)

RMT 2 weeks ago but it does not help

Diagnostic Tests:

Past Medical History: (CV, smoking, lungs, systemic, CA, OR, Trauma)

 Social History:

 lives with family


 tennis 3 times a week
 receptionist

Special Questions: None Patient Goals:


 Weight Loss  Steroids/Anti-coagulants
 Vertebral Artery signs  Cough/Sneeze
 Cord/Cauda Equina signs  Other:
Comments: _______________________________________
_________________________________________________
_________________________________________________
Signature: Esi Virant PT Date: (yy/mm/dd) 2016/05/20

1
Name: Leslie D DOB: Dominance: Left Right
Observation/Posture/Gait/Stairs: Neurodynamics:

 shoulder
 FHP

Scanning/Quick Tests/Other Joints/Functional/Ergonomics: Neuroconductivity:

UQS is negative except shoulder (N)

Range of Motion (Active/Passive):

Movement Right Left Comments/End Feel


shoulder flex 160 ERP
shoulder ABD 170 ERP scap rotation
shoulder H-ADD 70
shoulder EXT 60
shoulder IR 70
shoulder ER 90
*ERP = End Range Pain
Combined Movements/Quadrants/Repeated Movements: Passive Physiological Intervertebral Movements:

Resisted Isometrics (RIMS)/Manual Muscle Testing (MMT) Passive Accessory Movements:


RIMs:
ABD  ER  other shoulder mvts  N
Elbow flex = N
MMTs:
Muscle Right Left Special Tests:
IR  str
ER  Str
All impingement tests 
UFT N
LFT str
Bicep N
Length (Muscle)Tension Test: Palpation:
Muscle Right Left
neck muscles  bilat  bilat

Analysis: Problem List:


 FHP
® RC impingement syndrome   shoulder-ROM
  shoulder-strength
 tight neck muscles

Goals: Plan:
 Improve posture
  ROM  PT 3x/week
  strength  ROM ex
 play tennis  strength ex

Signature: Esi Virant PT Date: (yy/mm/dd) 2016/05/20

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