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Clinical Log Book: 3 YEAR, Batch IV (2014)

The document is a clinical log book and patient assessment form used by physical therapy students. It contains fields to record a patient's name, identifying information, medical history, examination findings, diagnosis, and planned treatment which includes electrotherapy, manual therapy, and other interventions. The form requires signatures from the student and their supervisor.

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Annie Khan
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86 views4 pages

Clinical Log Book: 3 YEAR, Batch IV (2014)

The document is a clinical log book and patient assessment form used by physical therapy students. It contains fields to record a patient's name, identifying information, medical history, examination findings, diagnosis, and planned treatment which includes electrotherapy, manual therapy, and other interventions. The form requires signatures from the student and their supervisor.

Uploaded by

Annie Khan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ZIAUDDIN COLLEGE OF PHYSICAL THERAPY

ZIAUDDIN UNIVERSITY

Clinical Log Book

DOCTOR OF PHYSICAL THERAPY


3RD YEAR, Batch IV (2014)

Student`s Name: ___________________________________________

Enrollment number: ________________________________________


Patient Assessment form
Name: ____________________________ MR No: __________ Gender: ________ Age: _____ Occupation:
_____________________ Referral/Doctor: ______________________________

Address: _____________________________________________________________________

Subjective Information:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________

Provisional Diagnosis:
Objective Information:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
__________________

Differential Diagnosis:

Examination:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________

Laboratory/Radiological Investigation:

________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________

Diagnosis:
Treatment Plan:

Electrotherapy:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________

Manual Therapy:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________

Others:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________

Outcomes/Prognosis:

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________

_____________________ _____________________

Signature supervisor Student signature

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