KNEE EVALUATION FORM Date: Pt Name: Pt Number: Diagnosis: Referred By: Visit #: Time In: Time Out: Billable Units

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KNEE EVALUATION FORM Date: Pt Name: Pt Number: Diagnosis: Referred By: Visit #: Time In: Time Out: Billable Units

University of Utah Department of Physical Therapy Student-Run Pro Bono Clinic KNEE EVALUATION FORM Date: Pt Name: Pt Number: Diagnosis: Referred by: Visit #: Time in: Time out: Billable units: Patient Information: Patient Profile: Chief Complaint: Account of Current Condition: History of present injury: Current Symptoms: Location: Onset: Character: Intensity: Duration: Aggravating Factors: Alleviating Factors: 24 hour behavior: PMH: Medication/Allergies: Current Function %: Standardized Functional Questionnaire: DASH: Modified Oswestry: NDI: LEFS: Personal and Environmental Factors: Activity: Occupation: Patient Goals: Systems Review: Cardiopulmonary: Neuromuscular: Integumentary: Musculoskeletal: Tests and Measures: Observation: Joint Clearing: University of Utah Department of Physical Therapy Student-Run Pro Bono Clinic ROM: AROM PROM End Feel R L R L R L Flexion Extension Internal Rotation External Rotation Resisted Tests: Flexibility: Neurologic Screen: Sensation Reflexes Motor R L R L R L L1-L2 L3 L4 L5 S1 S2 Special Tests: Valgus Stress Test: McMurray Test: Varus Stress Test: Thessaly Test: Lachman Test: Apprehension Test: Posterior Sag Sign: McConnell Test: Godfrey Test: Brush/Stroke Test: Active Drawer Test: Fluctuation Test: Drawer Sign: Patellar Tap Test: Lateral Pivot Shift Test: Joint Mobility: Palpation: Functional Tests: Today’s Intervention: Evaluation: Summary: Impairments: Functional Limitations: Response to today’s intervention: Plan of Care: Outcomes: STG: LTG: Prognosis: Intervention Plan: Informed Consent: University of Utah Department of Physical Therapy Student-Run Pro Bono Clinic ( Patient or Guardian) has been informed of all evaluation findings and treatment plans and agrees to participate in Physical Therapy services and plans as outline, including the given HEP. Sign: Date: .

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