INJURY EVALUATION
Name _____________________________________ Sport ____________________________
Report date ___________________________ Injury date ______________________________
Evaluator _____________________________ Signature ___________¡_________________
Subjective:
Relevant Past History:
Current History/Mechanism:
Objective:
Palpation:
ROM:
Evaluation Testing:
Assessment:
Plan:
|
X-ray |
r |
BAPS |
r |
Biodex |
r |
|
Ice Bag |
r |
Crutches NWB |
r |
Test |
r |
|
Ice Massage |
r |
Crutches PWB |
r |
Rehab |
r |
|
Slush Bucket |
r |
Ultrasound |
r |
Stretch |
r |
|
Cold Whpl. |
r |
NMES |
r |
MCL Prog. |
r |
|
Warm Whpl. |
r |
Massage |
r |
ACL Prog. |
r |
Contrast |
r |
Hydrocollator |
r |
R. Cuff Prog. |
r |
| Â oSplint |
r |
Cryostretch |
r |
Shoul. Flex. |
r |
|
Aircast |
r |
Traction |
r |
SAQ |
r |
Other ____________________________________________________________________________________
Physician Referral _____________________¡ ___________________________________________________
Physicianís Comments:
Physicianís Signature ______________________________________________ Date ______________________