<p>ANKLE & FOOT EVALUATION Name of Patient: ______Occupation: ______MD: ______Sports/Hobbies: ______Date of Injury: ______Date: ______Date of Surgery: ______Diagnosis: ______SUBJECTIVE Mechanism of Injury: ______Prior Level of Function: ______Current Functional Limitations: Sitting Standing Driving Participate in prior sports and rec activities Walking Sit  Stand Prolonged Sit/Stand/Walking Up/Down Stairs Pain Location: ______Pain Rating: __ Best __ Worse __ Average Radiating Pain: No Yes: ______OBJECTIVE WB Status: ______AD/Brace: ______Gait: ______Palpation: ______ROM MNT (5-Normal 4-Good 3-Fair 2-Poor) SPECIALTY TESTS R L R L + - DF ______Slump/SLR: PF ______Talar Tilt: Inv ______Anterior Drawer: Ever ______Thompson: HF ______Homan’s: HE ______TC/ST Mobility: Neuro: Sensation: _____ N ↑ ↓ Girth: R ______cm L ______cm Balance: Good Fair Poor Assessment: Current Problems: Decreased ROM Joint Hypomobility Swelling Decreased Strength Joint Hypermobility Gait Abnormalities Decreased NM Control Soft Tissue Dysfunction Balance Deficits Muscle Atrophy Other: ______Goals ↑ Ankle/Foot ROM __ degrees each plane to (I) sitstand and negotiate uneven surfaces wo subjective c/o’s ↑ Ankle/Foot Strength __ grade to (I) amb at work, school, grocery store, uneven surfaces wo subjective c/o’s ↑ WB status to FWB without assistive device subjective c/o’s ↑ Tolerance to PLOF, return to 100% PLOF – sports, recreational activities w no subjective c/o’s. Other: ______Rehab Potential: Excellent Good Fair Poor Discussed w/ pt goals/diagnosis/prognosis: Y N TREAMENT PLAN: TREATMENT FREQUENCY: ______TIMES/WK FOR ______WEEK(S) Therapeutic Exercise Neuromuscular Re-ed Modalities Gait Training Manual Techniques (Mobes, MFR) Home Exercise Program Traction (Manual / Mechanical) Other: ______</p><p>______Susana Delgado, PT, DTP Doctor Signature / Date</p><p>SUGAR LAND/STAFFORD GRAND PARKWAY/KATY WILLOW BROOK 711 AVENUE E 7830 W GRAND PKWY S 12539 PERRY RD STAFFORD, TX 77477 RICHMOND, TX 77406 HOUSTON, TX 77070</p>