Client Follow up and soap note

*Therapist Only*

Symptom
Tension Headache

TemplesForeheadTop of headEntire headbase of skullDizzinessfaintingLight-headesnesspain in earsRinging in earsUsually begin gradually and often occur in the middle of the dayHeadaches may last from minutes to several daysPressure around the forehead or back of the headMild to moderate constant band-like pain tightnessSleeping with the neck at an awkward positionFalling or sudden impact that pushes the head to the side, such as sports injuriesTurning the head side to side repeatedly during an activity, such as swimming the front crawl stroke
Neck Symptoms

Stiffnesspain when turning headpain in side shoulderpain deep in shoulder jointDiagnosed Arthritispain with side to side movementsneck feel out of placeMuscle spasm in neckGliding/grating sound with neck movementCan't raise arm above shoulder levelcan't raise arm over headHolding the neck in an abnormal position for a long period, such as cradling a phone between the neck and shoulderSlouching with poor posture while viewing the computer monitor or looking downward at a mobile phone for prolonged periods (sometimes referred to as "text neck")
Upper back muscle

A "Pulling on abnormal "stretching" feeling when back muscles are usedpain comes and goes depending on the specific naturepain is felt in the rhomboid, trapezius, infraspinatus, or latissimus Doris muscles.Upper back and shoulders painful
lower back muscle

Usually as dull and aching rather than burning, stinging, or sharp.Sometimes low back pain includes a sharp. stinging, tingling or numb sensation that moves down the thighs and into the low legs and feet, also called sciatica.Pain that is worse after prolonged sitting.pain up/down low backpain across low backlow back pain is worse when coughinglow back pain is worse when liftinglower back pain is worse when standingPain that feels better when changing positions.Pain in the morning is due to stiffness caused by long periods of rest.
Hip

Pain in buttockspain in buttocks when standingpain in buttocks when sittingpain on side of hippain deep in hip jointpain on sit boneDiagnosed bursitisDiagnosed arthritis
Frozen shoulder

Limited abduction outward rotationpain deep in shoulder jointpain down the upper outer side of the armcan not brushing the hair and inability to do up a brapain when putting on the coatpain reaching for the back pocketSevere sharp catching pain at the front of the shouldernight pain
Tennis Elbow

Pain is worse by stabilising or moving the wrist with forcepain is worse when shaking hands or squeezing objectsThe pain slowly increasing around the outside of the elbow
Golfer's Elbow

Tingling and numbness can sometimes be experiencedWeakness, Stiffness, and a general restriction of elbow movementPain inside of the upper forearm and muscles from the elbow joint to the wrist.
Carpal Tunnel Syndromes

Decreased grip strengthweakness of the handThese sensations more pronounced at night and can awaken from sleepInitially feel numbness and tingling of the hand in the distribution of the median nerve
Pitiformis Syndromes

Worse by sitting, climbing stairs, or performing squatsReferring pain along the course of the sciatic nervepain deep in the buttocks
Trochanteric bursitis

Sharp painSwelling over the bursaTenderness over the bony prominence of the upper/outer thigh
Hamstrings Strain

little loss of functionPain, some swelling, and stiffness in the back of the legStretching of the muscles and tendons
Knee Pain

Worsening pain when jump, run, squat, or climb stairspain in the right kneepain in the left kneeSwelling in the front of the knee or just below the kneecappain in both knees
Arms & Hands

Pain in upper armPain in forearmPain in wristpain in FingersSensation of pins & needles in armSensation of pins & needles in fingersfingers go to sleephands coldSwollen joints in fingerssore joints in fingersDiafnosed arthritisLoss of grip strength
Patellofemoral pain syndrome

Tight musclespain worsens when walking up or down hills or stairsSwelling sometimes occurs activityTenderness along the inside border of the kneecappain in the knee joint, particularly at the front, around and under the patella
Calf muscle pain

Tender lumps beneath the skinAching or throbbing at nightA cramping pain that comes on with exercise
Ankle Pain

Joints that are tender to the touchJoint swellingJoint pain
Achilles tendinitis

Swelling or thickening, redness over the Achilles tendonTenderness on palpationPain and stiffness in the Achilles tender especially in the morningPain over a period of a week
Migraine

An attack last between and 72 hoursNausea, vomiting, cold hand & feet, and sensitivity to light and soundMigraine headache aggravated by daily activities such as walking upstairsThe unilateral headaches typically change sides from one attack to the nextThe pain usually is unilateral (on one side of the head)Sometimes the pain is located in the forehead, around the eye, or at the back of the head
Depression

Agitation or irritabilitySignificant increase or decrease in appetiteloss of interest or pleasure in usual activitiescrying spellsfeeling and or blue
Stress

FatigueGastrointestinal disturbancesMuscle tensionSleep disturbances
Treatment Area

Rectus abdominisPectoralis minorPectoralis majorDorsal interosseous MusclesPlantar Interosseous MusclesLumbrical MuscleMuscles of footMuscles of LegPopliteusAchilles TendonPlantarisGastrocnemiusSoleusMuscles of HipSartoriusGluteus MuscleHamstringsPiriformisRectus FemorisQuadriceps FemorisQuadratus femorisMuscles of thighSerratusErector SpineObliqus AbdominisQuadratus LumborumLatissimus DorsiFlexor Carpi radialsCoracobrachialisBrachioradialisBrachialisTriceps BrachiiBiceps BrachiiDeltoidSupraspinatusInfraspinatussubscapularisTeres Major/ MinorLevator ScapulaeRhomboideus Major/MinorSternocleidomastoidOccipitalisMasticatory MusclesBack GastrocnemiusBack HamstringsBack Gluteal groupBack forearmsBack Latissimius DorsiBack Triceps BrachiiBack DeltoidsBack TrapeziusFront GastrocnemiusFront QuadricepsFront forearmsFront Abdominal MusclesFront Biceps BrachiiFront pectoral GroupFront DeltoidsFront TrapeziusEpicranial aponeurosisFrontalisOrbicularis oculiZygomaticusOrbicularis orisDepressor anguil orisTemporalisOccipitalisBuccinatorMasseterSternocleidomastoid
Massage Technique

Dry needlingMyofascial releasing techniquesArticulations of jointTrigger point therapySoft tissue releaseDeep transverse frictionCross fibre frictionDeep gliding fricitionSwedishConduction (Heat packs)Trigger point release techniquesManual lymphatic drainageMyofascial tension techniqueDeep tissue massage techniquestopical applicationsStretching TechniquesRadiationPetrissagePercussionCompressionFriction techniquesKneadingGliding techniquesPassive soft tissue movement
Special Test - Orthopedic Exam
HEAD & NECK Special Tests

Anterior Neck Flexors Strength TestAnterolateral Neck Flexors Strength TestCervical Compression TestCervical DistractionFirst Rib Mobility TestOrbicularis Oculi Strength TestPosterolateral Neck Flexors Strength TestSinus Transillumination TestSpurling’s TestSwallowing TestThree- Knuckle TestUpper Trapezius Strength TestVertebral Artery Test
HIP & PELVIS Special Tests

Ely’s TestFaber TestGaenslen’s TestGluteus Maximus Strength TestHamstring Strength TestHip Adductor LengthHip Quadrant TestIliopsoas Strength TestOber’s TestPace Abduction TestPiriformis Length TestPosterior SI Joint ProvocationSI Joint Gapping TestSI Joint Motion/ Gillet’s TestSI Joint Squish TestStraight Leg Raise TestSupine To Sit TestThomas TestTrendelenburg’s Sign
SHOULDER Special Tests

Acromioclavicular Shear TestAdhesive Capsulitis Abduction TestAdson’s TestCostoclavicular Syndrome TestDrop Arm TestEden’s TestHawkin’s Kennedy ImpingementInfraspinatus Strength TestMiddle Trapezius StrengthNeer ImpingementPainful Arc TestPectoralis Major LengthPectoralis Minor LengthRhomboids StrengthShoulder Adductors Length TestSpeed’s TestSubscapularis Strength TestSupraspinatus Strength TestTravel’s TestUpper Limb Tension 1Upper Limb Tension 2Upper Limb Tension 3Upper Limb Tension 4Wright’s Hyperabduction TestYergason’s Test
TRUNK & ABDOMEN Special Tests

Functional or Structural ScoliosisKemp’s TestKernig’s TestQuadratus Lumborum Length TestRebound Tenderness TestScoliosis Short Leg TestScoliosis Small Hemipelvis TestSlump TestValsalva’s TestVocal Fremitus Test
KNEE Special Tests

Apley’s Compression TestApley’s Distraction TestBragard’s SignClarke’s Patellofemoral Grind TestCoronary Ligamentous Stress TestGravity Drawer Test (aka Posterior Sign)Helfet’s TestLachman’s TestMajor Effusion Test (aka Ballottable Patella)Minor Effusion Test ( aka Brush Test)McConnell’s TestMcMurray’s TestNoble’s TestPatellar Apprehension TestQ ( Quadriceps ) AngleTrue Tibia and Femur Length TestValgus Stress Test of the KneeVarus Stress Test of the KneeWaldron’s Test
ANKLE & FOOT Special Tests

Anterior Drawer Test (Ankle)Babinski’s TestDeltoid Ligamentous Stress Test (Passive Relaxed)Functional Leg LengthFunctional or Structural Pes Planus TestHoman’s SignMorton’s NeuromaPosterior Drawer Test ( Ankle)Ramirez’s TestThompson’s Test (Achilles Tendon rupture)
Client's Feedback

Relieve migraine painRelax and soften injured, tied and overuesdReduce spasms and crampingLessen depression and anxietyIncrease joint flexiblityAlleviate low - back pain and improve range of muscleMuscle not as tight as beforeImprove flexibility and muscle conditionReduce pain and swellingJoint mobilityRelaxation skin NourishmentPain reductionMusle strengtheningSwelling reductionToxin CleaningBody Re-BlancingRemove StiffnessClaming of the peripheral NervesBlood Supply StimulationOther
Recommendations : (if any)
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