Physical therapy report
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Name : Smith, Bill |
Medicare ID : 1010101019 |
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Reason : Car accident |
Folder ID : 1234 |
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Diagnosis: low back pain |
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Treatment started on 1/1/1997 |
Number of treatment sessions: 26 |
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Dear Dr Wilson
After 26 sessions of treatment, we would like to inform you about the current state of Bill Smith.
Subjective statement
Lumbar spine: Significant improvement of the low back pain. Less radicular pain (60%) in the S1 root territory
Objective statement
Improvement in the active and passive range of motion of the lumbar spine. Restriction of range only in flexion (50%) and extension (40%). Light decrease of strength of the right gastronemius
Legend used in range of motion diagram.
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: Painless. |
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: Constrained or painful. |
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: Anatomical position. |
Lumbar spine
Range of motion
10/10/97 11/11/97
Analysis
The condition is improving on a normal rythm. The patient is highly compliant towards the rehabilitation process.
Treatment plan
The active rehabilitation is just starting on a progressive mode.
Please accept all our distinctive thanks, Dr Montagnais.
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Date |
The physiotherapist Dupont pht, 97-007 |
Your recommendations:
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Date |
Doctor's signature |
(Return this copy through the patient. Thank you)