Musculoskeletal Assessment

Client Name RiO ID

Date and time of completion of assessment
Age DOB
Address Postcode
General Practitioner Gender Male / Female
NHS number (10 digit number)

Specialty of User
Subjective Assessment
History of presenting musculoskeletal complaint
Description of symptoms:
Aggravating factors:
Easing factors:
24 hour pattern of presenting complaint: : (Identify: AM, PM and during the night)

Sleep Position
Supine Prone Sitting

Side lying - left Side lying - right Other ………………………………………………………

Other problems

General special questions: (See additional sheet)

Cervical spine special questions: (See additional sheet)

Lumbar spine special questions: (See additional sheet)

Peripheral joint special questions: (See additional sheet)

Comments:

Severity High Medium Low Comment:

Irritability High Medium Low Comment:
Nature:

Objective Assessment
Observations:

Cervical artery insufficiency:

Neurological tests – Upper limb: (Identify: Test name, right / left and outcome see additional sheet)

Neurological tests – Lower limb: (Identify: Test name, right / left and outcome see additional sheet)

Neurodynamic tests: (Identify: Test name and outcome see additional sheet)

Gait analysis:

Spinal assessment findings:

Peripheral joint findings:

Spinal and peripheral Joint (Identify specific joints Comment

joints cleared? - see additional sheet)

Palpation findings:

Accessory movements:

Muscle testing:

Other tests:

Podiatry Specific Questions

Peripheral Joint Muscle Flexibility: Comment
(Identify specific joints - see additional
sheet)

Comments:

Morphology: Left Right Comment

(Identify specific joints - see
additional sheet)
Weight Bearing Test Outcomes: Left Right
(Identify specific tests - see additional (Describe Outcome) (Describe Outcome)
sheet)

Comments:

Assessment summary:

Present at this Physiotherapist Podiatrist Healthcare Assistant Student

assessment:
Advocate Interpreter Parent Guardian
Partner Carer Other …………………………………………..……..

Referral
Onwards?
(Please give
details)
If referring to an organisation outside ONEL (Havering) please complete the Referral Out form

Progress
Notes:

Significant Progress Note: Yes / No

HCP Name

HCP Signature