History
Patient Information & Referral
Nationality
Saudi
Non-Saudi
Age
Gender
Male
Female
Source of Referral
Select referral details...
Referring Doctor
Referring Line
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Medicine
Surgery
PHC
Orthopedic
Neurology
ICU
Location of Evaluation
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Inpatient
Outpatient
Virtual
Home Visit
Reason for Consultation
Functional Impairment
Neurologic Evaluation
Musculoskeletal Evaluation
Pain Management
Spasticity Management
Prosthetic/Orthotic Evaluation
Post-Surgical Rehab
Coordination of Interdisciplinary Rehab
History of Present Illness (HPI)
Chief Complaint
(Patient's complaint as described)
HPI Details
Select HPI details...
Pain Assessment
Pain Intensity (VAS)
No Pain
Moderate
Severe
Pain Characterization
Describe the pain...
Side
Right
Left
Type
Sharp
Dull
Burning
Throbbing
Aching
Tingling / Numbness
Timing
Morning
Evening
Constant
With activity
Night
Intermittent
Behavior
Radiating
Localized
Area
Lower back
Neck
Shoulder
Knee
Hip
Ankle
Wrist
Elbow
Foot
General
Triggers
Walking
Standing
Sitting
Stairs
Lifting
Bending
Turning
Activity
Cold
After rest
Relief
Rest
Lying
Heat
Ice
Medications
Stretching
Movement
Position change
Massage
Avoidance
Past Medical & Surgical History
Medical History
Hypertension
Diabetes
Asthma
Osteoporosis
More Conditions
Coronary Artery Disease (CAD)
Congestive Heart Failure (CHF)
Chronic Kidney Disease (CKD)
Chronic Liver Disease
Chronic Obstructive Pulmonary Disease (COPD)
Visual Impairment
Hearing Impairment
Depression / Anxiety / PTSD
Dementia / Cognitive Impairment
History of Falls / Fractures
Surgical History
Operation:
Side
N/A
Right
Left
Bilateral
Date
How long ago?
day(s)
week(s)
month(s)
year(s)
Notes:
Examination
Fall Risk (Morse)
Low (0-24)
Moderate (25-44)
High (≥45)
Balance (Berg)
Normal (41-56)
Moderate risk (21-40)
High risk (0-20)
Coordination
Intact
Mild impairment
Severe impairment
Gait (Tinetti/TUG)
Normal
Minor abnormality
Major abnormality/Needs aid
Score/TUG(sec):
Gait Type
Normal
Antalgic
Ataxic
Spastic
Steppage
Trendelenburg
Shuffling
Circumduction
Choreiform
Muscle Tone (Ashworth)
0 - No increase
1 - Slight increase
1+ - Slight increase + catch
2 - More marked increase
3 - Considerable increase
4 - Rigid
Bladder Function
Continent
Incontinent
Retention
Catheter
Bowel Function
Normal
Constipation
Fecal incontinence
Retention
Sensation
Intact
Impaired
Absent
Skin Integrity
Intact
Redness
Breakdown/open wound
Pressure ulcer
Stage:
I
II
III
IV
Edema/Swelling
None
Mild
Moderate
Severe
Type:
Pitting
Non-pitting
Posture
Normal
Forward head
Kyphosis
Lordosis
Scoliosis
Anterior pelvic tilt
Posterior pelvic tilt
Genu varum
Genu valgum
Flat foot
Range of Motion (ROM)
Side
Joint
Movement
Result
Degrees
--
Right
Left
B/L
--
WNL
Limited
Add ROM Row
Manual Muscle Testing (MMT)
Side
Muscle
Grade (0-5)
--
R
L
B/L
Add MMT Row
Special Tests
Side
Test Name
Result
--
R
L
B/L
--
Positive
Negative
Other
Add Special Test
ADL Independence
Ambulation
Independent
Need Assistance
Dependent
Transfers
Independent
Need Assistance
Dependent
Toileting
Independent
Need Assistance
Dependent
Dressing
Independent
Need Assistance
Dependent
Feeding
Independent
Need Assistance
Dependent
Cognitive & Psychosocial
Cognition
Intact
Mild
Moderate
Severe
Memory
Intact
Mild
Moderate
Severe
Orientation
Person
Place
Time
Disoriented
Communication
Normal
Expressive Deficit
Receptive Deficit
Nonverbal
Mood / Behavior
Appropriate
Anxious
Depressed
Agitated
Reflexes (DTR)
Reflex
0
1+
2+
3+
4+
Biceps
Triceps
Brachioradialis
Patellar
Achilles
Diagnostic Image Findings
Plan
Diagnosis & Services
Diagnosis
This case is Urgent
Recommended Services
MSK
Neuro
PT Service
Pediatrics
Women's Health
Therapy Orders & Goals
PT (Physical Therapy)
Select PT goals...
Reduce pain
Improve joint range of motion (ROM)
Increase muscle strength and endurance
Improve balance and gait pattern
Enhance functional mobility and transfers
Improve posture and alignment
Train in safe use of assistive devices
Prevent musculoskeletal complications
Promote independence in ambulation
Educate on home exercise program
OT (Occupational Therapy)
Select OT goals...
Improve upper limb function
Enhance hand coordination and fine motor skills
Train in activities of daily living (ADLs)
Promote independence in self-care tasks
Adapt environment for safety and accessibility
Provide energy conservation techniques
Educate on use of adaptive equipment
Improve cognitive and perceptual skills
ST (Speech Therapy)
Select ST goals...
Improve speech clarity and articulation
Enhance language comprehension and expression
Manage swallowing difficulties (dysphagia)
Improve voice control and projection
Support cognitive-communication function
Educate family on communication strategies
P&O (Prosthetic / Orthotic)
Select P&O goals...
Ensure proper fitting and alignment
Provide functional training with device
Improve donning/doffing independence
Promote weight-bearing tolerance
Improve balance and gait with device
Prevent skin breakdown
Educate on use and maintenance
Equipment, Precautions & Referrals
Supports / Braces / Assistive Devices
Select items...
Elbow Support
Wrist Support
Back Support
Knee Brace
Ankle Support
Silicone Insole
Heel Pad
Cervical Collar
Walker Frame
Cane
Crutches
Thumb Spica
Arm Sling
Compression Stockings
Quad-cane
Tripod-cane
Side
R
L
Size
S
M
L
Precautions
Select...
No knee flexion beyond 90°
No hip adduction (don't cross legs)
No internal rotation
No deep squatting or kneeling
Avoid twisting motions
Avoid low chairs/toilets
No weight bearing on affected side (NWB)
Partial weight bearing on affected side (PWB)
No resistance training until cleared
NWB into TTWB as per protocol
No bending, lifting, twisting
No sitting >30 mins without support
No cervical extension
No weight bearing on affected side (NWB) for 6 weeks
Additional Referrals
Select...
Neurology
Orthopedics
Pain Specialist
Social Work
Physician Name
Date
Dynamic Narrative Report
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