Date of This Visit

Visit Type


Last Name of Patient

First Name of Patient

Date of Birth

Date of Surgery

Wound: Dressing

Wound: Sutures

Wound: Drainage

Wound: Redness

Inspection/Palpation: Knee Swelling

Inspection/Palpation: Calf Swelling

Inspection/Palpation: Calf Tenderness

Inspection/Palpation: Thigh Swelling

Inspection/Palpation: Thigh Tendernss

Motion: Straight Leg Raise

Motion: Knee Flexion (Please put a number)

Motion: Knee Extension (lack of full extension is a positive integer- for example a 20 flexion contr

Motion: Hip Flexion

Motion: Hip Extension- Is there a flexion contracture?


Function: Bed to Standing

Function: Standing to Chair

Function: Chair to Standing

Function: Stairs

Function: Gait

Function: Assistive Device Preferred

Pain: Did patient take pain medications prior to visit?

Pain: At Start of Session

Pain: At End of Session

Function: Check Those That Apply


Medications: General

Medications: Anticoagulation

Medications: Pain pill number

Medications: Pain pill frequency

Progress: Rating

Communication: Check Those That Apply


Communication: Contact Number to Call

Plan: Anticipate Further Visits

Discharge: Check Those That Apply


Discharge: Date of Surgeon Follow-up

Discharge: Date of OT/PT Follow-up


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