Form 1

0196-6011/84/0506-0348$02.
00/0
THEJOURNAL OF ORTHOPAED~C AND SPORTS PHYSICAL THERAPY
Copyright O 1984 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association
The Use of Standardized Evaluation

Forms in Physical Therapy
JOHN P. TOMBERLIN, PT,* JOHN S. EGGART, MS, PT, ATC,t LORI CALLISTER, PT, ATCt
The need for a consistent and efficient method of patient evaluation is not a new one.
Standardized evaluation forms that include body charts can be useful in recording
subjective and objective data in a systematic way. At the Physical Therapy Unit-
Student Health Center, University of Wisconsin-La Crosse, we have designed and put
into use this type of evaluation form.
We feel these evaluation forms allow us to perform consistent and efficient patient
evaluations in a short amount of time, especially for acute musculoskeletal injuries. A
method of controlling consistency is very important because of physical therapy and
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athletic training students and interns that rotate through the Physical Therapy Unit.
Because of the large volume of patients we see, there is a need for reducing the
amount of time needed in longhanding subjective, objective, assessment, and
planning (S.O.A.P.) notes. The standardized evaluation forms are an efficient
alternative to the longhand S.O.A.P. note.
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
The need for a consistent and efficient method The format of the forms is divided into four
of patient evaluation is not a new one. Standard- sections: subjective, objective, assessment, and
ized evaluation forms that include body charts can planning (S.0.A.P.).8,'3There are s'imilar features
be useful in recording subjective and objective to all the evaluation forms. The subjective section
data in a systematic way. At the Physical Therapy includes the following common items:
Unit-Student Health Center, University of Wis- -the mechanism of injury
Journal of Orthopaedic & Sports Physical Therapy
consin-La Crosse, we have designed and put into -previo~;s history of injury
use this type of evaluation form. -any pain, edema, numbness, or tingling pres-
We use a specific evaluation form depending ent now or at time of injury and have they
on the body area involved. Currently we have changed
divided the body into nine areas and have nine -did the patient hear or feel any sounds at
corresponding evaluation forms: Cervical Spine time of injury
(Fig. 1); Anterior Torso (Fig. 2); Lumbar Spine and -can patient ambulate now or at time of injury
Sacroiliac (Fig. 3); Distal Forearm, Wrist, Hand, without limp or pain (lower extremity injury)
Thumb, and Fingers (Fig. 4); Proximal Forearm Each objective section includes body charts to
and Elbow (Fig. 5); Shoulder (Fig. 6); Hip and mark findings of observation and palpation includ-
Thigh (Fig. 7); Knee (Fig. 8); Lower Leg, Ankle, ing any edema, deformity, discoloration, tender-
and Foot (Fig. 9). Evaluation forms specifically for ness, crepitus, etc., present. There is at least one
gait and posture are being compiled. (Currently body chart per form usually with the skeletal
there is not an evaluation form for the thoracic system outlined in the body part or area. Gener-
spine.) This list of evaluation forms is not neces- ally, the body charts include anterior, posterior,
sarily a complete one, and further subdivisions of medial, and lateral views. One set of body charts
the body areas may be needed. is for marking observation and palpation findings2
as previously mentioned, and another set is for
marking sensation test findings. The rest of the
Intern, Spring 1983, Mayo Foundation School of Allied Health Sci- objective section includes:
ences.
t Clinical Supervisors: Student Health Center-Physical Therapy Untt, -norms for AROM and pROM4 using the
University of Wisconsin-La Crosse, La Crosse, WI 54601. S.F.T.R. method of recording7
JOSPT MaylJune 1984 STANDARDIZED EVALUATION. FORMS 349
PIiYS I CAL THERAPY UEI I T Social Security # :

Student H e a l t h Center
U n i v e r s i t y o f Wisconsin-La Crosse
CERVICAL SPINE EVALUATION FORM
Name : -- P a i n f u l area: R or L or B or Center
Date o f i n j u r y : Date o f i n i t i a l evaluation-TR -PT :
S: Mechanism o f i n j u r y :
H i s t o r y o f previous i n j u r y :
What k i n d o f p a i n does p a t i e n t have? \(he r e ?
What changes p a i n and how
Constant p a i n or i n t e r m i t t e n t pain, Pain more severe? A.M. or P.M.
..........
Dizziness Y or N \dhen?
Stiffness .......... Y or N Where?
....
rlumbness o r t i n a l i n a ? Y or N \/here7
\,leakness? ..........
d 2
Y or N Where?
Other medical problems? ... Y or N What?
Ned i c a t i o n s ? ........ Y or E.4 !,/hat?
Docs p a t i e n t use a p i l l o w ? . Y or N \./hat k i n d ? When?
Comments: '
0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n , tenderness, c r e p i t u s , e t c . ,

and mark on body c h a r t .
Special t e s t s :
Compression .... + or -
Distraction .... + or -
Valsalva . . . . . .+ or -
Swallowing.. . . .+ or -
Adson ....... + or -
TMJ P a l p a t i o n ... + or -
Fig. 1
JOSPT Vol. 5,No. 6
ROM: S 40-0-40 SENSORY: Mark on body c h a r t f o r numbness,

F 45-0-45 t i n g l i n g , p a r e s t h e s i a , hypoesthesia,
R 50-0-50 r a d i a t i n g p a i n o r o t h e r symptoms.
MMT :
..
D e l t o i d (C5, a x i l l a r y N)
REFLEXES :
(C5)-Biceps. ... = .,
Biceps ( ~ 5 , 6 , musculotaneous
..
W r i s t E x t (C6, r a d i a l N)
......
(Cb) - B r a c h i o r a d i a l i s =
(C7)-Triceps ... = .
F i n g e r F l e x (C8) (C8) +!one

F i n g e r Abd ( ~ 1 ) . ...... (TI ) -None
P: S h o r t term g o a l s :
Mid term g o a l s :
Long t c r m goa 1 s :
AthleticTraining
-
Date PhysicalTherapy
-
Date PhysicianReview
-
Date
Eva 1 ua t o r Eva 1 ua t o r
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS 351
PllYS i CAL THERAPY UNIT S o c i a l S e c u r i t y hi:

U n i v c r s i t y o f Wisconsin-La Crosse
AIITER I OR TORSO EVALUATI ON FORM
Name : - P a i n f u l area: R or L or B or Center
Date o f i n j u r y : Date o f i n ; t i ; l c v a i u ~ t i o n - TR: PT :
S: biechanism o f i n j u r y o r onset o f p a i n :
H i s t o r y o f p r e v i o u s problems: -
Kind o f p a i n :
\./hat f' pain? \*ihct 6 pa i n ?

Consistant pain Y or N I n t e r m i t t e n t pain Y or N Weakness Y or N
Comments :
0: Observe and p a l p a t e f o r s w e l l i n g , deformi t y , d i s c o l o r a t i o n , tenderness, c r e p i t u s , e t c . ,

Sensory: Nark on body c h a r t f o r

numbness, t i n g 1 i ng , pa.rcs thes ia,
hypoesthesia, r a d i a t i n g p a i n o r
o t h e r symptoms.
Fig. 2
JOSPT Vol. 5, No. 6
0 : ROM:
MMT : Special t e s t s :
Upper r e c t u s abdominus S i t up
Lower r e c t u s abdominus Bilateral leg raise
Ext o b l ique -Left

-Riaht
-
d ~
I n t oblique Left
-Right
Comment s :
--
Long term goa 1 s :
---
A t h l e t i c Training Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Eva 1 ua t o r Eva 1 ua t o r
JOSPT MaylJune 1984 STANDARDIZED EVALUATION FORMS
PHYSICAL THERAPY UNIT Social Security #:

LUIlBAR SPl NE AND SACRO- I L IAC EVALUAT 10'1 FOfil?
Name : P a i n f u l area: R or L or B or Center
Date o f i n j u r y : Date o f i n i t i a l e v a l u ~ t i o n - T R : PT :
S : Mechanism o f i n j u r y o r o n s e t o f p a i n :
H i s t o r y o f p r e v i o u s i n j u r y o r p a i n episodes:
What k i n d o f p a i n does the p a t i e n t have?

....-. -.
Where?
-
P a t i e n t has p a i n - s t a n d i n o ? Y or N -
sittinq? Y or N - - prone? Y or N
-supine? Y or N -
other?
-coughing? Y or N -
b e a r i n g down? Y o r N - other?
P a t i e n t has p a i n c o n s t a n t l y o r intermittently?
What changes p a i n and how?

P a t i e n t has o t h e r i l l n e s s ? Y or N What?
P a t i e n t on m e d i c a t i o n ? Y or N What?
P a t i e n t n o t i c e d any weakness? Y or N Numbness? Y or No Tingling? Y or N
What i s c o n d i t i o n o f p a t i e n t ' s bed?
Observe and p a l p a t e f o r s w e l l i n g , Sensory:

d e f o r m i t y , d i s c o l o r a t i o n , tender- Mark on body c h a r t f o r numb-

ness, c r e p i t u s , e t c . , and mark on ness, t i n g l i n g , p a r e s t h e s i a ,
body c h a r t . h y p e r e s t h e s i a , hypoesthesia,
r a d i a t i n g pain o r other
symptoms.
Leg Length:
0,
Fig. 3
JOSPT Vol. 5, No. 6
0: ROM: Reflexes:
S 30-0-85 ( ~ 4 )Knee j e r k = , R>L , L7R
F 30-0-30 ( ~ 1 )Ankle j e r k a , R ? L , L?R
S L R . . . . . . + or -
Reverse SLR .. + or -
Babinski ... + or -
MHT :
11 i o psoas ( ~ 2 - 3 ) .
Quadriceps ( ~ 3 ) ..
T i b Ant ( ~ 4 ) .......
Ext Hal 1 i c u s ( ~ 5 ).
T r i c e p s Surae ( S l )
Hamstrings ( S l ) ..
G l u t Max ( s I ,2) ..
Special t e s t s : 1
Hoover t e s t ................ + or - Supine/Long s i t t i n g test... + or -
Supine-chin t o c h e s t ....... + or - Sacral push-cranial ........ + or -

Raise b o t h legs s t r a i g h t 2". + or - -caudal......... + or -
V a l s a l v a Maneuver........... + or - ........ +
P a l p a t i o n o f Sacrum or -
S 1 Compression .............. + or - I l i a c Rot-ant .............. + or -
S 1 Distraction.............. + or - -p ost.............
Gaenslin test............... + . or - Hip adduction/flexion ...... + or -
............. + - .... + .
Patrick's test or Check PSIS-raise L l e g or

Rectus abdominus.... ........ + or - .... +
-raise R leg or -
..... +
- f l e x trunk or -
Comments :
Long term goa 1 s :
- - -
AthleticTraining Date PhysicalTIierapy Date PhysicianReview Date
Eva 1ua t o r Eva 1ua t o r
PHYSICAL THERAPY UNIT Social Security # :

Un i v e r s i t y o f \.lisconsin-La Crosse
HAND, WRIST, FOREARM, THUMB, AND FINGERS EVALUATION
Name : - Affected side; R or L
Date o f i n j u r y : Date o f i n i t i a l evaluation-TR: -PT :
Has p a t i e n t f e l t o r heard any sounds?. . .Y or N Where?
Has p a t i e n t f e l t any numbness o r t i n g l i n g ? Y or N When?
Has p a t i e n t f e l t any weakness? . . . . . .Y or N When?

Where?
When does p a t i e n t have p a i n ? What k i n d ?
Where i s p a i n ?
What makes p a i n change?

0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t ion, tenderness, c r e p i tus,

e t c . , and mark on body c h a r t .
Palpation:
Fig. 4
356 TOMBERLIN ET AL JOSPT Vol. 5, No. 6
0: ROM: Norma 1 Active Pass i v e

Wrist S D - 60
F 20-0- 30
F i n g e r (11P) S 45-0- 90
(PIP) S 0-0-100
(DIP) S 10-0-90
Thumb ( I P) F 10-0- 80
(Mp) F 0-0-50
(CM) F 0 - 0 - 15
MMT : W
-- r i s t Finger -
--- Thumb
Flexion ..... F l e x NCP.. F l e x I1CP..
Extension. ... Ext FICP .. .
..--
Ext MCP..
Ulnar deviation . F l e x PIP.. Flcx !?.
Radial d e v i a t i o n . Ext PIP ..-- E x t 1P ....
Supination. ... F l e x DIP.. Abd C:1C. ..
..... Ext DIP .
Pronation Add CMC.. -

abd !<CP Oppos i t i o n
add MCP
Sensory: Mark on body c h a r t f o r

. numbness, t i n g l i n g , p a r e s t h e s i a ,
hypoesthesia, hyperesthesia,
Special t e s t s :
r a d i a t i n g p a i n o r o t h e r symptoms.
F l e x o r d i g i t o r u m s u p e r f i c i a l i s t e s t (PIP) + or -
F l e x o r d i g i t o r u m profundus t e s t (DIP) ..... + or -
I n t r i n s i c muscle t i g h t n e s s test........... + or -
Retinaculum t i g h t n e s s test................ + or -
Ulnar 6 Radial a r t e r y supply t e s t ......... + or -
D i g i t a l a r t e r y supply t e s t . . .............. + or -
Radial pulse .............................. = or R?L
or L)R
Comments :
-- -
Mid t e r m goal s:
Long term goa 1 s :
- -
AthleticTraining Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Eva 1 ua t o r Eva l ua t o r
PHYSICAL THERAPY UNIT S o c i a l S e c u r i t y #:

Student Neal t h Center
ELBOW AND PROX l IlAL FOREARM EVALUAT l ON FORM
Name : Affected side: R or L or B
Date o f i n j u r y : Date o f i n i t i a l evaluation-TR: -PT:
Did p a t i e n t f e e l any pop o r c l i c k ? ...... Y or N When?
Does p a t i e n t f e e l any numbness o r t i n g l i n g ? . Y or N When?

Does p a t i e n t f e e l any numbness o r t i n g l i n g now? Y or N Where?
Does elbow f e e l s w o l l e n ? . .......... Y or N
Has s w e l l i n g changed? .............Y or N

Does p a t i e n t have any weakness? ............... Y or N..Where?
Comments :
0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s l o c a t i o n , d i s c o l o r a t i o n , tenderness,

crepitus, etc., and mark on body c h a r t .
Med La t Ant Post
Pal p a t ion:
ROM: Normal Active Passive

S 0-0-150
R 90-0- 80
Fig. 5
TOMBERLIN ET AL JOSPT Vol. 5, No. 6
HMT : Neurological :
F l e x i o n (C5,6) ... Reflexes-
E x t e n s i o n (C7)... B i c e p s (C5) .......
.
S u p i n a t i o n (C5,6). Bracioradialis ( ~ 6 ) ...
P r o n a t i o n (C6,8-TI) . T r i c e p s (C7). ......
Special t e s t s : Sensory: H a r k on body c h a r t f o r numbness, t i n g -
Valgus s t r e s s . . . . .+ or - 1 ing, paresthesia, hypoesthesia, hyperesthesia,
Varus s t r e s s..... + or - h y p e s t h e s i a , r a d i a t i n g p a i n o r o t h e r symptoms.
Tinel sign ...... + or -
Tennis elbow t e s t . . . + or -
Compress u l n a & r a d i u s . + or -
Comments :
P: Short term goals:
- - ---
Mid term goals:
Long t e r m goa 1 s :
-- -
Athletic Training Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Eva1 u a t o r Evaluator
PttYS I CAL THERAPY UNIT Social Security #:

Student Hea 1 t h Center
SHOULDER EVALUATION FORM
Name : Affected side: R or L
Date o f i n j u r y : Date o f i n i t i a l evaluation-TR: -PT :
H i s t o r y o f previous ' i n j u r y :
Did p a t i e n t hear o r f e e l any sound?. Y or N When?
Does p a i n change7 ......... Y or N When?
Can p a t i e n t l i e on t h a t s i d e ? ... Y or N
I s the shoulder swollen? ......Y or N

Any change? ............ Y or N When?
Commcn t s :
0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n , tenderness, crepitus,

Palpation:
~ - -
- - ~
ROM: Normal Active Passive

S 50-0-170
Fig. 6
JOSPT Vol. 5, No. 6
IlMT : Neurological :
Flexion ( ~ 5 , 6 ) ........... Reflexes -
Biceps (C5) .= , R) L
Extens i o n (C5,6,7,8) ........ L7R
A b d u c t i o n (C5,6) .......... - Brachioradialis ( ~ 6 ) .
......
Adduct i o n ( ~ 5 , 6 , 7 , 8 - T I ) . = , R7L. L 7 R
E x t . Rot. (C5.6) .......... -Triceps (C7) .....
I n t . Rot. (C5,6,7,8-TI). ...... = , R)L, L7R
Scapular e l e v a t i o n (C3,4,5)..... Sensory: Mark on body c h a r t f o r
Scapular r e t r a c t i o n (C5) ...... numbness, t i n g l i n g , p a r e s t h e s i a ,
...
Shoulder p r o t r a c t i o n (C5,6,7). hypoesthesia, hyperesthesia,
Horizontal Abduction ....... r a d i a t i n g p a i n o r o t h e r symptoms.
H o r i z o n t a l Adduction ........
Special t e s t s :
Yergason t e s t .......... + or -
Drop arm t e s t ...,.......+ or -
........ +
Apprehension t e s t or -
.......... +
A-C t r a c t i o n or -
.... +
C l a v i c ! e movement a t A-C. or -
. +
lmpingment ( l n t . Rot. & F l e x . ) . or -
Quadrant.. .......... + or -
Locking ..............+ or -
...... +
E i c i p i t a l tendon t e s t or -
Comments :
Long term goal s :
A t h l e t i c Training Date P h y s i c a l Therapy Date P h y s i c i a n Review Date

Eva 1 u a t o r Eva 1 u a t o r
PHYSICAL THERAPY U N I T S o c i a l S e c u r i t y #:
HIP AND THIGH EVALUATION FORM

Date o f i n j u r y : Date o f i n i t i a l e v a l u a t i o n - TR PT
Does p a t i e n t f e e l p a i n ? Y or N Where?
What k i nd?
How lono?.,
What causes change?
Doespatientfeelswelling? Y or N Where?
Comments :
0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n , tenderness, c r e p i t u s ,

Pal p a t i o n :
Fig. 7
362 TOMBERLIN ET AL JOSPT Vol. 5. No. 6
0: ROM: -Normal
-- Active Passive
S 15-0-125 -
F (so) 45-0- 15
T(S90) 45-0- 20
R(SO) 45-0- 40
R (S90) 45-0- 45
MI1T :
MI1T -SEi<SC)RV
-- :
..
F l e x o r s ( L 1 ,2,3) Mark on body b o d ~c h a r t f o r numbness,
nu1nbness, t i n g l j n g ,
Extensors(S1) ... h y p o e s t: h e s i a , r a d i a t i n g p a i n o r
p a r a t h e s i a , hypoest
Abductors(L5) ... - o t h e r symptoms.
Adductors ( ~ 2 , 3 , 4 ). -
Ext. Rotators ...
I n t . Rotators ...
Special t e s t s :
SLR . . . . . . . . . . . . . . + or -
Trendelenburg . . . . . . . . .+ or -
. . + or -
I l i o - t i b i a 1 band t i g h t n e s s
Hip flexion tightness . . . . . + or -
Patrick's test . . . . . . . . + or -
. . : + or -
Compress i o n ( l n t Rot & Add)
. . + or -
( E x t Rot & Add).
. . . . apparent
Leg l e n g t h d i s c r e p e n c y + or true + or -
@ 0
Comments :
- - -- - -- - -- - -- -- -- ---
M i d t e r m goa 1 s : -
- --
Ath:etic Trainins Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Evaluator Eva 1ua t o r
PHYSICAL THERAPY UNIT S o c i a l S e c u r i t y #:

KNEE EVALUATION FORM
Name : A f f e c t e d Side: R or L or B
Date o f i n j u r y : Date o f i n i t i a l e v a l u a t i o n - TR PT
pp -
Has t h e knee locked? Yes or No When?
Has the knee g i v e n o u t ? Yes or No When?
I s t h e knee s w o l l e n ? Yes or No When?

Has t h e s w e l l i n g changed? Yes or No How?
Comments :
0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n , tenderness, c r e p i tus, e t c .

Observe g a i t: -
Palpation:
Fig. 8
0: ROM: Normal (S) 0-0-130 R Active -0 - R Passive

L Active -0 - L Passive- --0-O ----
Anthropometric: j t l i n e 2 " a b o v e j t l i n e 6"abovejtline
(5cm) (1 5cm)
Knee j e r k r e f l e x = , R 7 L, LrR Sensory: Mark on body c h a r t f o r numbness, t i n g l i n g ,

paresthesia, hypoesthesia, hyperesthesia,
MMT : . a i no r o t h e r svmotoms.
r a d i a t i n q. ~
Quadriceps (L2,3,4)
Hamstrinas (L5-S1)
Abductor; (~4;5-S
Adductors (L3,4)
Gastroc ( ~ 5 - ~ / 1 , 2 )
S a r t o r i u s (L2,3)
Attach o r t h o t r o n evaluation sheet.
Special t e s t s :
Lachman's ............ + or .
...
Valgus S t r e s s ( f u l l e x t ) . ..+ of - (20) f l e x . . . . . .+ or -
.....
Varus s t r e s s ( f u l l e x t ) + or - ( 2 0 ~ )f l e x ) . . . . . .+ or -
Drawer ( a n t ) .......... + or - (Post) . . . . . . . .+ or -

...
Slocum's R o t a r y ( i n t r o t ) . + or - (ext r o t ) . . . . . . .+ or -
Apley (comp) .......... + or - (dis t) . . . . . . . .+ or .
Bounce home .......... . + or -
Apprehension ..........
.
1 . l ~H u r r a y (Valgus w i t h e x t r o t ) +
+
or
or
-
-
(Varus w i t h i n t . rot.). + or -
........
P a t e l l a r Grinding + or .
P a t e l l a r Ballotment
Chondromalacia t e s t s
. .. .. .. .. .. ..
+
+
or
or
.
-
Comments :
Mid t e r m g o a l s :
Long t e r m g o a l s :
- -- - --
A t h j e t i c Training Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Eva 1 ua t o r Evaluator
PIIYS I CAL THERAPY UNIT S o c i a l S e c u r i t y #:

U n i v e r s i t y o f W i sconsi n-La Crosse
FOOT, ANKLE, AND LOWER LEG EVALUATION FORM

Date o f i n j u r y : Date o f i n i t i a l e v a l u a t i o n - T R : -PT:
D i d p a t i e n t hear or f e e l any sound? ..... Y or N What?

When?
I s p a t i e n t a b l e t o walk on a f f e c t e d s i d e ? Y or N..at t i m e o f i n j u r y ? Y or N
...
w i t h o u t 1 imp? Y or N..at t i m e o f i n j u r y ? Y or N
...
without pain? Y or N..at t i m e o f i n j u r y ? Y or N
i s the ankle swollcn? .................... Y or El
Has t h e s w e l l i n g changed? ................ Y or N..How?
0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n , tenderness, crepi tus,

Observe g a i t : ( ~ t t a c hg a i t e v a l u a t i o n i f n o t enough space)
-
Ankle j e r k r e f l e x
A n t h r o p o m c t r i c ( F i g . 8)
Pulses-Dorsal Pedal =
', R>L,
L>R
L>R
0
-Posterior Tibia1 = , R)L, L)R
TOMBERLIN ET AL JOSPT Vol. 5. No. 6
0: ROM:
Ankle ................... -
A c t-
ive Passive
Hind Foot... ............

Fore Foot ...............
...............
G r e a t Toe (MP) ..........
( I?). .........
2nd t o 5 t h Toes (HP) ....
Which Toe? (PIP) .....
(DIP) .....
MMT :
T r i c e p s Surae ( ~ ,1 2)...... --
SENSORY:
tingling,
Mark on body c h a r t f o r numbness,
paresthesia, hypoesthesia,
T i b Ant ( ~ 4 ) .............. r a d i a t i n g p a i n or o t h e r symptoms.
.....
Ankle i n v e r t o r s ( ~ 5 ) .
Ankle Evertors ( ~ 1 ) . ......
2-5 Toe E x t e n s i o n (L5) ....
2-5 Toe F l e x i o n (L5) ...... -

.
G r e a t Toe E x t e n s i o n ( ~ 5 ) .
G r e a t Toe F l e x i o n (L5) ....
Special Tests:
Ant Drawer ................. + or -
Lateral Stability .......... + or -
....
Ankle D o r s i f l e x i o n Test t i g h t gastroc, t i g h t soleus, o r -
R i g i d F l a t Feet Test....... + or -
T i b i a i Torsion Test ........ + or -
Calcaneous Tap T e s t ........ + or -
T i b - F i b Compress-Proximal .. + or -
....
-Distal + or -
.....
P a l p a t e Post-med T i b i a + or -
Comments :
Mid term goals :
--
Athletic T r a i n i n g Date P h y s i c a l Therapy Date P h y s i c i a n Review Date
Evaluator Evaluator
Name : SS#:
Last First
M F
Impress ion Classification
Treatment Intens i ty/Frequency/Durat ion
Re-eva 1 Dates
Comments
Fig. 1A
Name : SS# :
Last First
M F
Treatment Intensity/Frequency~Duration
Re-eva l Dates
Comments
Fig. 2A
Name : SS#:
Last First
M F
Impress ion Class i f i c a t i o n
Treatment Intens i :y/Frequency/Duration
Re-eva l Dates
Fig. 3A
Name : SS# :
Last First
M F
Treatment I n tens i ty/Frequency/Durat ion
Re-eva l Dates
Comments
Fig. 4A
Name : SS#:
Last First
.. .
T rea tnen t I n t e n s i ty/Frequency/Duration
Re-eva 1 Dates
Comrnen t s
Med Lat Ant Pos t

Fig. 5A
Name : SS#:
Last First
M F
impress i o n Class i f i c a t i o n
Treatment I n t e n s i ty/Frequency/Durat i o n
Re-eva 1 Dates
Comments
Fig. 6A
370 TOMBERLIN E T AL JOSPT Vol. 5, No. 6
Name : SS#:
Last First
M F
Treatment Intensity/Frequency/Du~ation
Ke-eva 1 Dates
Conrnen t s
Fig. 7A
Name : SS#:
Last First
M F
Treatment Intens i ty/Frequency/Durat ion
Re-eva 1 Dates
Fig. 8A
Name : SS#:
Last First
M F
impress ion Class if ication
Treatment Intensity/Frequency/Duration
Re-eva l Dates
Fig. 9A
-Manual Muscle T e ~ t ~ ~ ~ ~ l ' trolling consistency is very important because of

-reflexes and sensationlo physical therapy and athletic training students and
-special tests for the specific body area3~9~12 interns that rotate through the Physical Therapy
-anthropometric measurement^'^^ Unit-Student Health Center, University of Wis-
-space for comments consin-La Crosse. Because of the large volume
The assessment section has space for a spe- of patients we see, there is a need for reducing
cific written assessment of the injury. the amount of time needed in longhanding
The planning section is divided into short-term, S.O.A.P. notes. The standardized evaluation
mid-term, and long-term goals. These should in- forms are an efficient alternative to the longhand
clude the overall goal, the treatment program S.O.A.P. note.
(intensity, frequency, and duration), the type of There is a continuing effort to revise and im-
treatment, and the result expected. Treatment prove this system.
flow sheets (see Figs. 1A through 9A) with body
charts are attached to the evaluation forms with REFERENCES
specific orders for use by aides and physical 1. Arnheim DD, Klafs CE: Conditions of the knee: atrophy measure-
therapy students and with the date of re-evalua- ment. In: Modern Principles of Athletic Training, Ed 3, p 292. St.
tion to be done by the evaluating therapist. Louis: CV Mosby Co, 1973
2. BasmajianJV: Surface Anatomy: An Instruction Manual. Baltimore:
The patients (students) are directly referred by Williams & Wilk~ns,1977
physicians in the Student Health Center (or by 3. Birnbaum JS: The Musculo-Skeletal Manual. New York: Academic
personal physicians that the patients have seen) Press lnc, 1982
4. Cole TM, Tobis JS: Measurement of musculoskeletal function. In:
to physical therapy for evaluation and treatment Kotke FJ, Stillwell GK, Lehman JF (eds). Krusen's Handbook of
programs. The majority of patients we see have Physical Medicine and Rehabilitation, Ed 3. Philadelphia:WB Saun-
musculoskeletal disorders, i.e., acute ortho- ders Co, 1982
5. Daniels L, Worthingham C: Muscle Testing: Techniques of Manual
paedic, athletic injuries, and postsurgical patients. Examination, Ed 3. Philadelphia: WB Saunders Co, 1972
We feel these evaluation forms allow us to 6. Esterson PS: Measurement of Ankle Joint Swelling Using a Figure
perform consistent and efficient patient evalua- of 8. J Orthop Sports Phys Ther 151-52,1979
7. Gerhardt JJ: SFTR Recording of Joint Motion and Position in the
tions in a short amount of time, especially for Neutral-Zero Method. Bess Kaiser Hospital-Permanante Clinic,
acute musculoskeletal injuries. A method of con- Portland, OR, 1980

8. Hill JR: The Problem-OrientedApproach to Physical Therapy Care. 12. Ramamurti CP, Tinker RV: Orthopaedics in Primary Care. Balti-
Washington, DC: American Physical Therapy Association, 1977 more: Williams & Wilkins, 1979
9. Hoppenfelt S: Physical Examination of the Spine and Extremities. 13. Stolov WC: Evaluation of the patient. In: Kotke FJ, Stillwell GK,
New York: Prentlce-Hall Inc, 1976 Lehman JF (eds), Krusen's Handbook of Physical Medicine and
10. Hoppenfeld S: Orthopaedic Neurology: A Diagnostic Guide to Rehabilitation, Ed 3. Philadelphia: WB Saunders Co, 1982
Neurologic Levels. Philadelphia: JB Lippincott Co, 1977
11. Kendall HO, Kendall FP: Muscles: Testing and Function. Baltimore:
Williams & Wilkins, 1971

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The Use of Standardized Evaluation

PIiYS I CAL THERAPY UEI I T Social Security # :

CERVICAL SPINE EVALUATION FORM

Name : -- P a i n f u l area: R or L or B or Center

Date o f i n j u r y : Date o f i n i t i a l evaluation-TR -PT :

What k i n d o f p a i n does p a t i e n t have? \(he r e ?

What changes p a i n and how

Constant p a i n or i n t e r m i t t e n t pain, Pain more severe? A.M. or P.M.

0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t i o n , tenderness, c r e p i t u s , e t c . ,

ROM: S 40-0-40 SENSORY: Mark on body c h a r t f o r numbness,

F i n g e r F l e x (C8) (C8) +!one

PllYS i CAL THERAPY UNIT S o c i a l S e c u r i t y hi:

AIITER I OR TORSO EVALUATI ON FORM

Name : - P a i n f u l area: R or L or B or Center

Date o f i n j u r y : Date o f i n ; t i ; l c v a i u ~ t i o n - TR: PT :

\./hat f' pain? \*ihct 6 pa i n ?

Consistant pain Y or N I n t e r m i t t e n t pain Y or N Weakness Y or N

0: Observe and p a l p a t e f o r s w e l l i n g , deformi t y , d i s c o l o r a t i o n , tenderness, c r e p i t u s , e t c . ,

and mark on body c h a r t .

Sensory: Nark on body c h a r t f o r

Ext o b l ique -Left

Long term goa 1 s :

PHYSICAL THERAPY UNIT Social Security #:

LUIlBAR SPl NE AND SACRO- I L IAC EVALUAT 10'1 FOfil?

Name : P a i n f u l area: R or L or B or Center

What k i n d o f p a i n does the p a t i e n t have?

What changes p a i n and how?

Observe and p a l p a t e f o r s w e l l i n g , Sensory:

d e f o r m i t y , d i s c o l o r a t i o n , tender- Mark on body c h a r t f o r numb-

Supine-chin t o c h e s t ....... + or - Sacral push-cranial ........ + or -

Patrick's test or Check PSIS-raise L l e g or

Long term goa 1 s :

PHYSICAL THERAPY UNIT Social Security # :

HAND, WRIST, FOREARM, THUMB, AND FINGERS EVALUATION

Name : - Affected side; R or L

Date o f i n j u r y : Date o f i n i t i a l evaluation-TR: -PT :

Has p a t i e n t f e l t o r heard any sounds?. . .Y or N Where?

Has p a t i e n t f e l t any numbness o r t i n g l i n g ? Y or N When?

Has p a t i e n t f e l t any weakness? . . . . . .Y or N When?

When does p a t i e n t have p a i n ? What k i n d ?

What makes p a i n change?

0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s c o l o r a t ion, tenderness, c r e p i tus,

0: ROM: Norma 1 Active Pass i v e

Pronation Add CMC.. -

Sensory: Mark on body c h a r t f o r

Long term goa 1 s :

PHYSICAL THERAPY UNIT S o c i a l S e c u r i t y #:

ELBOW AND PROX l IlAL FOREARM EVALUAT l ON FORM

Name : Affected side: R or L or B

Date o f i n j u r y : Date o f i n i t i a l evaluation-TR: -PT:

Did p a t i e n t f e e l any pop o r c l i c k ? ...... Y or N When?

Does p a t i e n t f e e l any numbness o r t i n g l i n g ? . Y or N When?

Does p a t i e n t f e e l any numbness o r t i n g l i n g now? Y or N Where?

Does elbow f e e l s w o l l e n ? . .......... Y or N

Has s w e l l i n g changed? .............Y or N

0: Observe and p a l p a t e f o r s w e l l i n g , d e f o r m i t y , d i s l o c a t i o n , d i s c o l o r a t i o n , tenderness,

Med La t Ant Post

ROM: Normal Active Passive

P: Short term goals:

Mid term goals:

PttYS I CAL THERAPY UNIT Social Security #:

SHOULDER EVALUATION FORM