Physical therapy report

 

Name : Smith, Bill

Medicare ID : 1010101019

Reason : Car accident

Folder ID : 1234

Diagnosis: low back pain

 

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.

: Painless.

: Constrained or painful.

: 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.

 

 

 

 

 

Date

 

The physiotherapist Dupont pht, 97-007

 

Your recommendations:

 

 

 

 

 

 

 

 

 

 

Date

 

Doctor's signature

 

 

(Return this copy through the patient. Thank you)