Lower Extremity Evaluation
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Patient Name
*
First Name
Last Name
Team and Jersey
*
Ex: Spurs 08 G Blue
Date of Birth
*
-
Month
-
Day
Year
Date
Guardian Name
*
First Name
Last Name
Date of the initial consultation
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Range of Motion?
WNL
Decreased
Unable to complete
Other -
Strength?
WNL
Decreased
Unable to complete
Other -
Did you preform any special test? What were the results?
Diagnosis?
Was the player able to RTP
Was treatment administered? If so, what?
Does this patient need further imaging/evaluation?
Yes
No
Would patient/parent like assistance in making an appointment?
Yes
No
Healthcare Provider Name
First Name
Last Name
Healthcare Provider Number
LAT Number
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