Joint Clinical Assessment Form
Please complete the following assessment to document joint evaluation findings and clinical impressions.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clinician Name
*
First Name
Last Name
Joint Assessed
*
Please Select
Knee
Shoulder
Hip
Elbow
Ankle
Wrist
Other
Laterality
*
Left
Right
Bilateral
Primary Symptom
*
Pain
Swelling
Stiffness
Instability
Reduced Range of Motion
Other
Symptom Duration
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Pain Severity (at rest)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Functional Limitations
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable
Walking
1
2
3
4
5
Climbing stairs
6
7
8
9
10
Standing up
11
12
13
14
15
Grasping objects
16
17
18
19
20
Swelling Observed
*
None
Mild
Moderate
Severe
Clinician Plan / Summary
*
Submit Assessment
Should be Empty: