The document is an orthopedic assessment form that collects detailed subjective and objective data from patients, including personal, medical, and pain histories. It includes sections for general examination, sensory and motor evaluation, and specific assessments related to limb function and diagnostic goals. The form is structured to support the establishment of provisional diagnoses and treatment plans.

1. ORTHOPEDIC ASSESSMENT
SUBJECTIVE ASSESSMENT
Name - __________________ Age/Gender - ________________
Address - _______________________________________________________________________
Occupation - __________________ File No. - _______________
Date of Admission - _______________ Contact No. - __________________
Date of Assessment - ______________
Chief Complaint:
Anterior Posterior
Present History of Illness:
Past History:
Family History: Heart Disease/ Hypertension/ Stroke/ Diabetes/ Cancer/
Asthma/ Migraine/ Epilepsy/ Other ____________________________________________
Personal History:
Do you use tobacco products? YES/NO (how many packs per day?) - ________
Beer, Wine, or other Alcoholic beverages? YES/NO (Units per week?) - _______
Do you exercise regularly?

2. If yes, then which type? - _______________ From how much time? - __________
Average Sleep per night - _______________
Socioeconomic History:
With whom do you live? - _________________________________________________________
Have you experienced any major life changes during the past few years? (such
as New baby, Job change, Death of a family member) - YES/NO
Any major problem in the family? -
___________________________________________________
Financial Status (High/ Middle/ Low) - __________________
Medical History: Heart disease/ Hypertension/ Stroke/ Diabetes/ Cancer/
Asthma/ Migraine/ Epilepsy/ Other_________________________________________________
Past Surgical History:
Drug History:
Do you take any prescribed medications? - ________________________________________
Do you take any non-prescribed medications? - ___________________________________
Allergies to medications? - __________________________________________________________
Pain History:
Type of pain :
TYPE OF PAIN STRUCTURE
Cramping, dull, aching Muscle
Dull, aching Ligament, Joint capsule
Sharp, shooting Nerve Root
Sharp, bright, lightning-like Nerve
Sharp, severe, intolerable Fracture
Side of pain: _______________________

3. NPRS (Numerical Pain Rating Scale) -
OBJECTIVE ASSESSMENT
General Examination - Height: _________ Weight: _________
Vitals -
On Observation -
On Palpation -
Site of Pain: ________________________
Pain Onset: (Gradual/Instantaneous)
Pain Intensity (on a scale of 1-10): _______
Pain Frequency: (Constant/Intermittent)
Pain Aggravating Factors: (e.g., certain movements, sitting, standing, weight-
bearing) ___________________________
Pain Relieving Factors: (e.g., rest, heat, cold, medications) _____________________
Blood Pressure - ____________ (120/80 mmHg)
Pulse Rate - _________________ (60-100 bpm)
Temperature - ______________ (97.5°-99.5° F)
Respiratory Rate - __________ (16-20/min)
Body Built (Endomorphic/mesomorphic/ectomorphic) - ______________________
Posture (Standing/ Sitting)- ______________________________________________________
Swelling - YES/NO _________
Redness - YES/NO _________
Skin changes - _____________________________________________________________________
Limb length Discrepancy? ________________________________________________________
Attitude of Limb - _________________________________________________________________
Deformities - ________________________
Gait - _______________________________________________________________________________
Warmth/Cold - ________________
Edema - _______________
Tenderness - Grade 1/2/3/4
Spasm - _______________________

4. On Examination
Sensory Examination -
Superficial Sensations:
Crude touch: _________
Deep Sensations:
Cortical Sensations:
Crepitus - _____________________
Limb length measurement - ___________________
Muscle Girth - ________________
Touch - Fine touch: _________
Pain Sensation - Normal/ Abnormal _________________
Temperature sensation - Normal/ Abnormal ________________
Joint Position Sense - Normal/ Abnormal _________________
Kinesthesia - Normal/ Abnormal __________________
Two-point Discrimination - Normal/ Abnormal _________________
Steriognosis - Normal/ Abnormal _________________
Graphisthesia - Normal/ Abnormal _______________

5. Motor Examination
Lower Limb
Spine
Range of Motion (ROM) - Upper Limb
JOINT MOVEMENT RANGE END FEEL
Shoulder
Elbow
Forearm
Wrist
Hands and
Fingers
JOINT MOVEMENT RANGE END FEEL
Hip
Knee
Ankle
Foot
JOINT MOVEMENT RANGE END FEEL
Cervical Spine
Thoracic Spine
Lumbar Spine

6. Stride length - .........................
Step length - ...........................
Manual Muscle Testing (MMT) :
Reflexes :
REFLEX LEFT RIGHT
Superficial Abdominal
Plantar
Deep Biceps
Brachioradialis
Triceps
Knee
Ankle
Posture -
Gait :

7. Cadence (number of steps/minute) - ............................
Walking Velocity (Distance walked/time) - ..........................
Speed - Free speed/ Slow speed/ Fast speed .......................
Width of base of support - .......................... (Normal - 3.5 inches)
Degree of toe out - .......................... (Normal - 7°)
Differential Diagnosis:
Investigations:
Provisional Diagnosis:
Diagnosis:
Goals:
Treatment Plan:
Bladder - Spastic/Flaccid/ Autonomous ______________________
Short term Goals
Long term Goals