ABSTRACT
200 201 202 203 204 205 206 Confidential Patient Information
Patient Name (or attach ID Label)
Hospital/NHS Number
Date of Birth
Address
Home Telephone Number
Work Telephone Number
Mobile Telephone Number
ALL STAFF SIGNING FOR CARE MUST RECORD BELOW DETAILS OF THEIR FULL NAME, POSITION AND SAMPLE SIGNATURE
POSITION
FULL NAME
SIGNATURE
INITIAL
EXT
Date of Initial Assessment
Date of Follow-up Appointment
1.
2.
3.
4.
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Clinical Nurse Specialist
Add
Adductor
GP
General Practitioner
Flex
Flexion
SpR
Specialist Registrar
Ext
Extension
PT
Physiotherapist
UL
Upper limb
OT
Occupational Therapy
LL
Lower Limb
Pt
Patient
R
Right
ITB
Intrathecal Baclofen
L
Left
BT
Botulinum Toxin
DIP
Distal Interphalangeal Joint
IP
Intrathecal Phenol
PIP
Proximal Interphalangeal Joint
ISC
Intermittent Self Catheterisation
MCP
Metacarpophalangeal Joint
LMWH
Low molecular weight heparin
MTP
Metatarsophalangeal Joint
INR
International Normalised Ratio
EMG
Electromyography
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Acceptable abbreviations used in this proforma
Upper Limb
Delt
Deltoid
ECR
Extensor carpi radialis
Lat d
Latissimus dorsi
ECU
Extensor carpi ulnaris
Pec Maj
Pectoralis major
E dig
Extensor digitorum
Pec Min
Pectoralis minor
E dig min
Extensor digiti minimi
Biceps
Biceps brachii
EPL
Extensor pollicis longus
Brach
Brachialis
EPB
Extensor pollicis brevis
BR
Brachioradialis
Add poll
Adductor pollicis
FCR
Flexor carpi radialis
Abd poll
Abductor pollicis brevis
FCU
Flexor carpi ulnaris
Lumb
Lumbricals
FDS
Flexor digitorum superficialis
Pron ter
Pronatus teres
FDP
Flexor digitorum profundus
Pron quad
Pronator quadratus
FPL
Flexor pollicis longus
Supin
Supinator
FPB
Flexor pollicis brevis
Lower Limb
Add mag
Adductor magnus
Tib ant
Tibialis anterior
Add long
Adductor longus
Tib post
Tibialis posterior
Add brev
Adductor brevis
EDL
Extensor digitorum longus
Semi-m
Semi-membranous
EHL
Extensor hallicus longus
Semi-t
Semi-tendinous
Gastroc
Gastrocnemius
Biceps f
Biceps femoris
Soleus
Soleus
Psoas
Psoas Major
FHL
Flexor hallicus longus
Iliac
Iliacus
FHB
Flexor hallicus brevis
FDB
Flexor digitorum brevis
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