exercise hysiology and functional …csusap.csu.edu.au/~sbird/ehr503/ancillary/initial consultation...
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♦ Cliff Blake Auditorium ♦ Charles Sturt University ♦ Bathurst NSW 2795 ♦ Tel: 02 6338 4064 ♦ Fax: 02 6338 4065 ♦ Email: [email protected] ♦
EXERCISE PHYSIOLOGY AND FUNCTIONAL REHABILITATION CLINIC
INITIAL CONSULTATION SOAP NOTES
Surname: _________________________________ First name: ___________________________ Date: ___ / ___ / ___
Phone (wk): _______________________ (AH or Mob): ______________________ No. of services: ______________
Exercise Physiologist: _____________________________________________________________ Time: ___________
1. REASON FOR CONTACT:
2. SUBJECTIVE DATA:
3. GOALS:
Short-term (7-14 days):
Long-term (8-12 weeks):
♦ Cliff Blake Auditorium ♦ Charles Sturt University ♦ Bathurst NSW 2795 ♦ Tel: 02 6338 4064 ♦ Fax: 02 6338 4065 ♦ Email: [email protected] ♦
EXERCISE PHYSIOLOGY ANDFUNCTIONAL REHABILITATION CLINIC
4 OBJECTIVE DATA Height: __________ cm Weight: __________ kg BMI: __________ RHR: __________ bpm (Regular/ Irregular) Target HR ranges: HRmax (220-age): ________ HRR: _______ 50%: _______ 60%: _______ 70%: _______ 80%: _______ Blood Pressure: __________ mmHg FEV1: __________ FVC: __________ FEV1/FVC: __________ Waist circumference: __________ cm Hip circumference: __________ cm WHR: ______________ Bodyshape: Endomorph / Ectomorph / Mesomorph _________________________________________________ Posture: Normal / Lordosis / Kyphosis / Scoliosis _________________________________________________ Sit and reach: _____________________________________________________________________________________ Flexion: _____________________________________________________________________________________ Extension: _____________________________________________________________________________________ Hyperextension: _____________________________________________________________________________________ Lateral Flexion: (R) _______________________________ (L) _______________________________ Supine Leg Raise: (R) _______________________________ (L) _______________________________ Bicep curls (30s): (R) _______________________________ (L) _______________________________ Sit to stand (30s): _____________________________________________________________________________ 6-minute walk: End-test HR: _____________ (80%HRR) Gait Aid: __________________________________
Limiting factor to the test: SoB HR Leg fatigue ______________________________
Total distance covered: __________________________________________________________ Astrand Cycle Ergometer: End-test HR: _____________ (80%HRR) Stage completed:___________________________
Limiting factor to the test: SoB HR Leg fatigue ______________________________
Estimated maximal oxygen consumption (VO2max) value: _________ ml•kg•min SF-36 Health Questionnaire: ___________________________________________________________________________ Roland-Morris LBP/disability Questionnaire: ________________________________________________________________ NOTES ___________________________________________________________________________________________________
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♦ Cliff Blake Auditorium ♦ Charles Sturt University ♦ Bathurst NSW 2795 ♦ Tel: 02 6338 4064 ♦ Fax: 02 6338 4065 ♦ Email: [email protected] ♦
EXERCISE PHYSIOLOGY ANDFUNCTIONAL REHABILITATION CLINIC
5. PLAN
6. ADDITIONAL COMMENTS:
7. REVIEW: