ELBOW/WRIST/HAND 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:
ADL Deficiency Reaching Overhead activities Participate in prior sports
Sleeping Driving Carrying / Lifting
Pain Location: ______Pain Rating: __ Best __ Worse __ Average
Radiating Pain: __ No __ Yes ______
OBJECTIVE
WB Status: ______Assistive Device/Brace: ______
Palpation: ______
AROM Strength AROM Strength
R L R L R L R L
Elbow Flexion ______Wrist Flexion ______
Elbow Exten. ______Wrist Exten. ______
Elbow Pron. ______Radial Deviat. ______
Elbow Supin. ______Ulnar Deviat. ______
Special Tests: Hand: Thumb Index Middle Ring Small
Lateral Epicondylitis: +- MCP: ______
Medial Epicondylitis: +- PIP: ______
Tinel’s Sign: +- DIP: ______
Finkelstein’s: +-
Assessment:
Current Problems:
Decreased ROM Joint Hypomobility Swelling Muscle Atrophy
Decreased Strength Joint Hypermobility Gait Abnormalities
Decreased NM Control Soft Tissue Dysfunction Balance Deficits
Other: ______
Goals
↑ ROM ____ degrees each plane to (I) dress by manipulating button, zippers, ties on cloths
↑ Strength ____ grade to (I) perform ADL’s wo subjectives c/o’s
↓ Or abolish sx’s to (I) perform ADL’s wo subjective c/o’s
↑ olerance 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 Therapy Home Exercise Program
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