LOWER BACK TEMPLATE

Subjective

What is the nature of the pain?

Acute

Chronic

Acute on Chronic

What is the intensity of the pain?

Rest

Pain can spike to?

Where is the pain located?

Left

Right

Alternates side to side

Bilateral

Are there any neurological signs associated?

No neurological signs

Yes neurological signs

Aggravating factors?

Bending forward

Bending backwards

Sitting for long periods

Standing for long periods

Sitting

Putting socks and shoes on

Gym exercises

Other

Easing factors?

Heat

Rest

Stretching

Movement

Massage

Heat Cream

Medications

When is the pain worse?

Mornings

Throughout the day

Night time

Not consistent

With activity

What investigations/interventions have been conducted?

Steroid Injection

Imaging

Previous physiotherapy treatment

Previous chiropractic treatment

Nil previous investigations or interventions

Any red flags?

No red flags

Red flags

Past medical history?

Auto-immune conditions

Diabetes mellitus

Hypertension

Nil relevant past medical history

Objective

Active range of motion (AROM)

Functional tests

Muscle Length Tests

Tender on Palpation

Hip joint

Neurodynamic Assessment

Outcome Measures

Action

Passive modalities

Active modalities

Education and advice

Plan

Follow up appointment required

Independently manage and review on request

Advised to follow up with Doctor

Referral to health professional