Athletic Therapy Initial Evaluation (Musculoskeletal)

Date: [Date] Time: [Time] Location: [clinic / field / training room] Encounter Type: Initial Evaluation

Patient: [Full name] Age: [Age] Sex: [Sex]

Clinician: [Clinician name], [Credentials]

Sport Context: [Sport]; [Position/Event]; [Level]; [Season phase]; [Dominant side if relevant]

(Use laterality [R/L/bilateral] throughout. Use 0-10 pain scale. When information is unavailable, document explicitly: "Denied," "Unknown," "Not assessed—[reason]," or "Deferred—[reason]." Do not infer findings not documented. Omit sections not clinically relevant; if typically performed but skipped, briefly state why.)

Chief Complaint

[Patient-stated reason for evaluation with anatomical location and onset anchor] (1-2 sentences. Use direct quotes when wording is clinically meaningful. Do not include diagnostic terms unless confirmed by an authorized provider.)

History of Present Injury

[Narrative of mechanism of injury and course] (Include contact vs. noncontact; sudden vs. gradual onset; immediate symptoms; ability to continue activity; evolution since onset. If onset circumstances unclear, note "Unknown" with brief explanation of how history was obtained.)

Location & Symptom Quality: [Region and laterality; pain / instability / clicking-locking / numbness-tingling description]

Pain Severity (0-10): Rest [0-10]; With provocation [0-10]; 24-hour pattern [description]; Night pain [present / absent—details]

Aggravating Factors: [Movements, positions, sport-specific tasks]

Easing Factors: [Rest, medications, modalities, positions]

Swelling/Bruising: [immediate / delayed / denied; location and extent]

Prior Care Since Onset: [Self-care; medications; imaging; other providers; response]

Functional Impact: [Gait; stairs; running; cutting; jumping; throwing; lifting—include region-dependent tasks]

Previous Injuries/Surgery (same region): [History details / Denied]

Red Flag Screen

• Systemic symptoms: [Pertinent positives/negatives: fever, unexplained weight loss, malaise]
• Neurologic changes: [Pertinent positives/negatives: progressive weakness, dermatomal numbness, bowel/bladder changes if spine]
• Vascular concerns: [Pertinent positives/negatives: asymmetric swelling/warmth, color/temperature changes]
• Fracture/dislocation indicators: [Pertinent positives/negatives: inability to bear weight, deformity, focal bony tenderness, high-energy mechanism]
• Pain behavior: [Pertinent positives/negatives: unremitting pain not linked to movement]

Red Flag Status: [No red flags identified. / Red flags present—see below.]

Red Flag Findings and Disposition: [Findings identified; actions taken; disposition (referral / ED / EMS); who was notified] (Include only if red flags present or uncertain.)

Relevant Medical History

• Medical conditions affecting rehab: [Conditions such as diabetes, bleeding disorders, connective tissue disease / None relevant]
• Surgical history (region-specific): [Relevant procedures and dates / None]
• Current medications (relevant): [Agents affecting healing, bleeding, inflammation, or contraindications / None relevant]
• Allergies/sensitivities: [Medication / adhesive / latex / Denied]

Baseline Function and Goals

Pre-injury function/participation level: [Training volume; role; workload; baseline capacities]

Patient-stated goals: [Functional and sport-specific goals]

Patient-reported outcome (PRO): [Instrument name, score, date / PRO not collected—will obtain at follow-up]

Objective Examination

Observation: [Posture; swelling/effusion; bruising; deformity; skin changes; surgical scars; gait or relevant functional observation; assistive devices/bracing]

Palpation: [Tender structures by anatomical location; warmth; effusion; bony vs. soft tissue tenderness]

Range of Motion: (Include bilateral comparison; use degrees; include only motions assessed.)

Motion	Side	Active ROM (°)	Passive ROM (°)	Notes (pain onset angle, end-feel, limiting factor)
[Motion]	[R / L]	[Value]	[Value / —]	[Notes]

Strength: (Include bilateral comparison when relevant; specify method and whether pain-limited.)

Muscle/Action	Side	Grade/Measurement	Method	Pain-limited	Notes
[Muscle/Action]	[R / L]	[Grade or value]	[MMT / Dynamometry]	[Yes / No]	[Notes]

Neurological Screen: (Include only if indicated by presentation; omit entirely if not indicated.)

• Sensation: [Dermatomal/peripheral distribution findings]
• Myotomes: [Findings]
• Reflexes: [Findings]
• Neural tension tests: [Tests and results]
• Distal neurovascular status: [Pulse, cap refill, sensation, motor] (For acute limb injuries.)

Special Tests: (Group by clinical hypothesis; include only tests performed.)

• [Hypothesis group]:
  • [Test name] — [positive / negative / equivocal] ([Brief interpretation if needed])

Functional Testing: [Baseline performance on participation-relevant tasks; qualitative observations of movement faults; quantitative measures if feasible / Deferred—[reason]]

Assessment

[2-4 sentence synthesis summarizing key history elements, primary objective impairments, and functional limitations. State whether red flags were identified and actions taken.]

Clinical Impression / Working Diagnosis: [Primary working impression with brief supporting/contradicting findings; differential considerations if appropriate] (If referral warranted, state: "Concern for [condition]; recommend referral to [provider type].")

• Impairments: [ROM deficits; strength deficits; pain; swelling; motor control]
• Activity limitations: [Specific tasks affected]
• Participation restrictions: [Sport / work / school impacts]

Prognosis: [Expected functional course and timeframe; factors supporting or limiting prognosis]

Plan of Care

Participation Status (today): [Full participation / Modified participation / No participation] — [Specific restrictions and protections]; [Criteria for progression]

Interventions Today: [Interventions provided and patient response] (Omit if no treatment beyond evaluation.)

Home Program: [Exercises with dosing (sets/reps/frequency) or reference to attached program; activity modification guidance; symptom monitoring instructions; criteria for seeking urgent care]

Goals:

• Short-term (1-2 weeks): [Measurable criteria: ROM degrees, pain reduction, initial functional milestones, PRO change]
• Long-term / Episode: [Measurable criteria: strength symmetry %, functional test performance, return-to-sport criteria, PRO target]

Planned Interventions: [Therapeutic exercise categories; neuromuscular re-education; manual therapy; modalities; progressive return-to-sport conditioning; patient education] — [Key measures to reassess]

Frequency and Duration: [Visit frequency] for [Estimated duration]; outcome measures to be repeated [timeline]

Referral/Coordination: [To whom; reason; communication status] (Omit if no referral needed.)

Signature

[Clinician name], [Credentials] — [Date signed] [Time signed]