JOURNAL

Date:      

Name: Phone: Born:
Address: Treatment from: Diagonsis:




Physiotherapist Name:    
       
Referal Details                                    Date:

Treatment start date :             Last Treatment:             Total Treatment

Main Findings

Physical Function         Can manage      With a little help Cannot Notice
Sit up in bed YES | NO YES |NO YES | NO YES |NO
Swing legs outside
Bed edge
YES | NO YES |NO YES |NO YES |NO
Stand / sit
At bedtime
YES |NO YES |NO YES |NO YES |NO

 

 

 



USER AID

View OK | IMPAIRED Walker YES |NO
Hearing OK |IMPAIRED Pulpit YES |NO
Language OK | Affected Wheelchair YES |NO
Gait  OK |Reduced Elevator YES |NO


 
    Movement    Reduced     Stiff     Note
The Neck YES | NO YES |NO YES |NO YES |NO
Shoulder YES |NO YES |NO YES |NO YES |NO
Elbow                        YES |NO YES |NO YES |NO YES |NO
Wrist  Joint YES |NO YES |NO YES |NO YES |NO
The back YES |NO YES |NO YES |NO YES |NO
Hip                        YES |NO YES |NO YES |NO YES |NO
Knee                       YES |NO YES |NO YES |NO YES |NO
Ankle YES |NO YES |NO YES |NO YES |NO

Short term Goal:

Long Term Goal:

Proposals for further action: