Report Presented by: _______________________

PATIENT CASE HISTORY & FEEDBACK REPORT

Name:______________________ Age/Gender __________ Mob No. _______________ E-Mail Id: ____________________

Presenting Complaints__________________________________________________________________________________

_____________________________________________________________________________________________________

Any Medical/ Surgical History____________________________________________________________________________

Observation & Examination

Pain Scale_________________ Deformity ________________ Swelling__________________ Tenderness_______________

Muscle Strength ____________________________________ ROM______________________________________________

Any Investigation Done__________________________________________________________________________________

Provisional Diagnsis____________________________________________________________________________________

Treatment Details:

Patient Feed Back:

1 How do you feel now ? __________________________________________________________________________

2 What difference you find the day you came for therapy and today ?_______________________________________

3 How was your experience with Class IV Laser Therapy? _________________________________________________

4 How was the quality of treatment ? _________________________________________________________________

5 Is there any suggestion you like to provide ? __________________________________________________________

6 Any Other ? ____________________________________________________________________________________

Signature of Patient