doctor initial evaluation – Bout2bebetter App

I. Subjective

Today's symptom report before treatment

Documentation only. Click each heading to open/close its related options.

Symptom Severity

None = 0 / 10 Mild = 1–3 / 10 Moderate = 4–6 / 10 Severe = 7–10 / 10

Symptom Behavior

Spine Away from Spine Local Diffuse

Measurement of Perceived Barrier

Primary perceived barrier

Documentation only

Pain Stiffness / mobility restriction Weakness / deconditioning Symptoms after activity Fear of re-injury Uncertainty about how to move safely Reduced endurance

Recovery capacity

No lasting symptoms = 0 <1 hour = 2 1–24 hours = 4 >24 hours = 6

Self-Management Since Last Visit

Home exercise program

Documentation only

I practiced repeated movements to manage my symptoms I practiced my prescribed home exercise program I have made postural changes and…

II. Objective

Benchmark test: postural dysfunction identifier

Not yet scored

Posture: loading response

Documentation only

Forward head (tech neck) Asymmetrical gaze: looking over to screen Overhead activity

Activity tolerance: direct effects of intervention

Return to being active; no longer deferring activity = 0 Engaging in activity that was previously painful = 1 Able to load exercise that was previously painful = 2 Improved activity duration: time/mileage = 3

Limiting activity: intervention

Documentation only

Sustained posture at work station Loading (wt lifting/gym exercise/ADLs) Plyos (running, return to sport)

Directional preference

Extension = 0 Side glide = 1 Rotation = 1 Flexion = 4 Flexion with rotation = not yet defined No directional preference = not yet defined

IV. Assessment

Symptom behavior

Centralization achieved = 0 Centralization not achieved = 2

Protocol progression See Assessment Score

III. Physical Therapy Goals Achieved

Functional goal

Sustained posture at work station = 0 Loading (wt lifting/gym exercise/ADLs) = 4 Plyo's (running/return to sport) = not yet defined

Home Exercise: Intervention

Directional preference

Documentation only. This second copy is not included in the score.

Extension Side glide Rotation Flexion Flexion with rotation No directional preference

Protocol # See Assessment Score

Subjective After Treatment

Assessment Score

Total is computed on save. Fields with unconfirmed point values are safely stubbed at 0 until Dr. Johnson confirms the values.

Initial Evaluation

Mechanical Assessment SOAP Note

See Assessment Score

Re-evaluate Patient

I. Subjective

Pain Location

Right, Left, or Both

Symptom Severity

Symptom Behavior

Measurement of Perceived Barrier

Self-Management Since Last Visit

II. Objective

IV. Assessment

III. Physical Therapy Goals Achieved

Home Exercise: Intervention

Subjective After Treatment

Pain Location

Right, Left, or Both

Symptom Severity

Symptom Behavior

Assessment Score