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Initial Evaluation and Treatment Plan- Ankle/Foot Evaluation

Date of Eval: ____________ Date of Onset:____________
Place Label Here Diagnosis: ________________________________________

History/Mechanism of Injury: _____________________________________________________________

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Psychosocial/Functional Deficits: __________________________________________________________
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PMH: _________________________________________________________________________________
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Current Medications: ____________________________________________________________________
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Symptomology: Constant_____ Intermittent_____ Variable_____ Unchanging _____ Daily _____
 or  symptoms with activities _______________________
Pain Pattern/Intensity (0-10 scale): Rest______ Activity______
Comments: __________________________________________ L R R L R L
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Observation/Inspection: ________________________________ Sketch location
Can of pain
draw body here
area here
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Gait: ________________________________________________
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Proprioception/Somatosensory: __________________________
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+ = pain AROM L AROM R PROM L PROM R Strength L Strength R

Ankle DF
Ankle PF
Ankle INV
Ankle EVER
Great Toe Flex
Great Toe Ext
Toe II-V Flex
Toe II-V Ext
Palpation:______________________________________________________________________________
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Joint Play Assessment: ___________________________________________________________________
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Special Tests: __________________________________________________________________________
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HEP/Patient Education: __________________________________________________________________
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ASSESSMENT: ________________________________________________________________________
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Problems/Physical Findings: ______________________________________________________________
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TREATMENT PLAN: __________________________________________________________________
Patient will be seen ______ x/wk for ______ wks or ______ visits for _____________________________
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GOALS BY

Barriers to achieving treatment goals?  Yes  No ___________________________________________

Family/patient involved in and verbalized understanding of goals?  Yes  No ____________________
Patient was instructed in ankle/foot model as it pertains to the injury?  Yes  No __________________

Clinician: