PKB often gets requests from teams to create a treatment or proforma care plan that they can use with their patient cohort. This type of plan is completed regularly, as required, over a period of time while the patient is either going through treatment or receiving a form of rehab. These care plans can often be lengthy with lots of information and content. PKB has created a basic template that can be adapted to suit your patient cohort and team specialty.

Have a look through the template and let your Success PM know what content (text and information) you want to add.

What’s Contained in a PKB Care Plan?

PKB will always show in the care plan any diagnoses, allergies, and medications that have been entered in the patient record. The main body of the plan includes an action plan. The action plan can include information on the patient's care, health goals, and advice on monitoring their conditions. (Including video or web links). Key symptoms and measurements can also be selected to track and display for the patient.

Long Care Plan Template

At the top of the care plan, there are links to the different sections within the plan, and unlike a shorter care plan, after each section, there is a button that takes you to the top of the plan again (back to top). This care plan is divided into 10 clear sections. Each section is clearly defined by the black borderline and within each section, the font is clear and text spaced out with the intention that the content is easy to read and digest.

ACL Reconstruction Proforma Care Plan Template

<div class="form-inline"> <style media="screen"> .form-group {width: 100%; !important} .cpwhiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; border-radius: 10px; border: 3px solid #014151;} </style> <div class="cpwhiteBox" id="top"> <ul> <li style="list-style:inherit; margin-left: 15px;"><a href="#1">Screening and Consent tool</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#1a">Occupational Therapy Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#2">Stage 1 Initial Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#3">Stage 2 Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#4">Stage 3a Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#5">Stage 3b Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#6">Stage 4 Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#7">Stage 5 Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#8">Stage 6 Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#9">Stage 7 (4 months) Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#10">Stage 8 (5 months) Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#11">Stage 9 (6 months) Assessment</a></li> <li style="list-style:inherit; margin-left: 15px;"><a href="#12">Return to Sport (9 month) Assessment</a></li> </ul> </div> <div class="cpwhiteBox" id="1a"> <h1>Screening/Consent Checklist Tool, Physiotherapy OPD/Group Rehabilitation London Road Community Hospital (UHDB Trust)</h1> <h2>1 Consultation Types</h2> <div class="cpwhiteBox"> <p><b>Telephone consultation (T/C)</b> allows a full history of your condition to be taken. There may be some capacity to assess movement & function, but there is the possibility of missing some clinical detail. There is no risk of being infected with coronavirus with this consultation type.</p> <p><b>Video consultation (T/M)</b> allows a partial, but not full physical examination and there is the possibility of missing some clinical detail. You will need Google chrome or safari and a microphone and camera. There is no risk of being infected with coronavirus with this consultation type.</p> <p><b>Face to face consultation (F2F)</b> involves coming into the hospital for Physiotherapy/OT. This will allow a full physical assessment and treatment, if necessary. The F2F process is not risk free; contact with your therapist and possibly other individuals increases the risk of being infected with coronavirus. We have strict infection control measures in place to minimise this risk.</p> <p>Having heard the pros and cons of each consultation type do you prefer a telephone consultation (T/C), a video consultation (T/M) or a face to face consultation (F2F).</p> <div class="row"> <div class="col-sm-6"> <label for="cp_consultType"><h3>Patient choice of consultation</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_consultType" id="cp_consultType"> <option value="--">Select</option> <option value="Telephone consultation (T/C)">Telephone consultation (T/C)</option> <option value="Video consultation (T/M)">Video consultation (T/M)</option> <option value="Face to face consultation (F2F)">Face to face consultation (F2F)</option> </select> </div> </div> <p><b>T/C or T/M go to 4(c) F2F go to 2</b></p> </div> <h2>2 Covid-19 Screening</h2> <p>Have you or your household members experienced any of the following symptoms over the past 14 days?</p> <div class="row"> <div class="col-sm-6"> <label for="cp_highTemp"><h3>High Temperature</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_highTemp" id="cp_highTemp"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_contCough"><h3>New continuous cough</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_contCough" id="cp_contCough"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_tasteChange"><h3>Change in taste/smell </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_tasteChange" id="cp_tasteChange"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>3 Covid-19 Risk Screening</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_3a"><h3>a) Have you received a letter from the NHS or been told by your GP that you are high risk? Are you shielding? Such as organ transplant, severe lung condition etc. <b>HIGH RISK</b></h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_3a" id="cp_3a"> <option value="--">Select</option> <option value="Yes 4">Yes 4</option> <option value="No 3 (b)">No 3 (b)</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_3b"><h3>Are or have you any of the following? Age ≥ 70, BMI ≥ 40, diabetes, pregnancy, liver, heart or chronic kidney disease, lung condition (non-severe), brain/nervous system condition, condition that increases infection or taking immunosuppresants <b>MODERATE RISK</b></h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_3b" id="cp_3b"> <option value="--">Select</option> <option value="Yes 4">Yes 4</option> <option value="No 3 (c)">No 3 (c)</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_3c"><h3>(c) LOW RISK</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_3c" id="cp_3c"> <option value="--">Select</option> <option value="Have none of the above">Have none of the above</option> </select> </div> </div> <h2>4 Informed Consent:</h2> <h3>(a) Infection Control/Risk with Covid-19</h3> <div class="row"> <div class="col-sm-5"> <p>Explain the safety and infection control measures in place to minimise risk with a F2F consultation.</p> <div class="row"> <div class="col-sm-6"> <label for="cp_infectionUnderstand"><h3>Select to confirm understood</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_infectionUnderstand" id="cp_infectionUnderstand"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> </div> <div class="col-sm-7"> <p><i>On attending your appointment, you will have a temperature check and you will be given a mask to wear during your consultation. Your therapist will also be wearing personal protective equipment. </i></p> <p><i>We adhere to the Hospital Trust's current infection control measures.</i></p> </div> </div> <div class="row"> <div class="col-sm-5"> <p>Explain the risks of contracting Covid-19</p> <div class="row"> <div class="col-sm-6"> <label for="cp_covidUnderstand"><h3>Select to confirm understood</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_covidUnderstand" id="cp_covidUnderstand"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> </div> <div class="col-sm-7"> <p><i>Despite these measures, the risk of infection is still present as people may be infected & spread it to others without knowing.</i></p> <p><i>If you become infected you could become seriously unwell or die.</i></p> </div> </div> <h3>(b) Clinical Risk/informed choice</h3> <div class="row"> <div class="col-sm-6"> <label for="cp_highRisk"><h3><b>HIGH RISK</b> - You have been identified as being extremely clinically vulnerable. Knowing the risks and infection control measures in place, do you still prefer to have a F2F consultation</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_highRisk" id="cp_highRisk"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_moderateRisk"><h3><b>MODERATE RISK</b> - You have been identified as being clinically vulnerable. Knowing the risks and infection control measures in place, do you still prefer to have a F2F consultation?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_moderateRisk" id="cp_moderateRisk"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_lowRisk"><h3><b>LOW RISK</b> - You have been identified as having low clinical vulnerability. Knowing the risks and infection control measures in place, are you happy with having a F2F consultation?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_lowRisk" id="cp_lowRisk"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h3>(c) Questions or Concerns</h3> <div class="row"> <div class="col-sm-6"> <label for="cp_q4Concerns"><h3>Do you have any questions or concerns? </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_q4Concerns" id="cp_q4Concerns"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_q4concernsAddressed"><h3>Have the questions/concerns been addressed? </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_q4concernsAddressed" id="cp_q4concernsAddressed"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_validation"><h3>Validate choice of consultation - </h3></label> <textarea class="form-control" name="cp_validation" id="cp_validation" rows="10" style="width: 100%;">Name _______________________________ consents to a _____________ consultation</textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy1"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy1" id="cp_completedBy1" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date1"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date1" id="cp_date1" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time1"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time1" id="cp_Time1" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="1b"> <h1>Occupational Therapy Assessment</h1> <h2>Employment details</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_occupation"><h3>Occupation:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_occupation" id="cp_occupation" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_employer"><h3>Employer:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_employer" id="cp_employer" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_shiftPattern"><h3>Normal hours/shift pattern:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_shiftPattern" id="cp_shiftPattern" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_jobDescription"><h3>Description of job role:</h3></label> <textarea class="form-control" name="cp_jobDescription" id="cp_jobDescription" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_dutiesAvailable"><h3>Potential light duties available:</h3></label> <textarea class="form-control" name="cp_dutiesAvailable" id="cp_dutiesAvailable" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_absenceStart"><h3>Start of sickness absence date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_absenceStart" id="cp_absenceStart" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_noteExpiry"><h3>Sick note/fit note expiry date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_noteExpiry" id="cp_noteExpiry" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_returnDate"><h3>Any plan/date for return to work:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_returnDate" id="cp_returnDate" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <h3>If employed:</h3> <div class="row"> <div class="col-sm-6"> <label for="cp_dueToInjury"><h3>Is it due to their condition/ injury?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_dueToInjury" id="cp_dueToInjury" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_lastEmployed"><h3>When were they last employed?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_lastEmployed" id="cp_lastEmployed" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_previousEmployType"><h3>Type of previous employment:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_previousEmployType" id="cp_previousEmployType" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_mainBarriers"><h3>What does the patient perceived to be main barriers for return to work (stamina to complete full hours, physical requirements of work tasks, confidence, employment support, financial)</h3></label> <textarea class="form-control" name="cp_mainBarriers" id="cp_mainBarriers" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_sickBenefits"><h3>Sick pay/benefits:</h3></label> <textarea class="form-control" name="cp_sickBenefits" id="cp_sickBenefits" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_initialAdvice"><h3>Any initial advice provided by OT:</h3></label> <textarea class="form-control" name="cp_initialAdvice" id="cp_initialAdvice" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>Discharge assessment</h2> <h3>Working Patients:</h3> <div class="row"> <div class="col-sm-6"> <label for="cp_rtw"><h3>Has the patient RTW?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rtw" id="cp_rtw"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_employedSameCompany"><h3>If YES are they employed by the same company?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_employedSameCompany" id="cp_employedSameCompany"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_resumeNormalHours"><h3>If YES have they resumed normal hours?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_resumeNormalHours" id="cp_resumeNormalHours"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_returnToDuties"><h3>If YES have they returned to normal duties?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_returnToDuties" id="cp_returnToDuties"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_rtwNo"><h3>If NO for what reasons?</h3></label> <textarea class="form-control" name="cp_rtwNo" id="cp_rtwNo" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_receiveBenefits"><h3>Is the patient currently in receipt of benefits?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_receiveBenefits" id="cp_receiveBenefits"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_whatBenefits"><h3>If YES, what are they?</h3></label> <textarea class="form-control" name="cp_whatBenefits" id="cp_whatBenefits" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_gpLetter"><h3>Was a letter or report written to their GP or place of work?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_gpLetter" id="cp_gpLetter"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_workAssessment"><h3>Did they have a work assessment?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_workAssessment" id="cp_workAssessment"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h3>Non-working Patients:</h3> <div class="row"> <div class="col-sm-6"> <label for="cp_rtwNon"><h3>Has the patient RTW?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rtwNon" id="cp_rtwNon"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_fullPartTime"><h3>If YES is it full time or part? Full time/part time</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fullPartTime" id="cp_fullPartTime"> <option value="--">Select</option> <option value="Full Time">Full Time</option> <option value="Part time">Part time</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_activleySeeking"><h3>If NO are they actively seeking employment?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_activleySeeking" id="cp_activleySeeking"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_whatReason"><h3>If NO for what reasons?</h3></label> <textarea class="form-control" name="cp_whatReason" id="cp_whatReason" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_receiveBenefits2"><h3>Is the patient currently in receipt of benefits?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_receiveBenefits2" id="cp_receiveBenefits2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_whatBenefits2"><h3>If YES, what are they?</h3></label> <textarea class="form-control" name="cp_whatBenefits2" id="cp_whatBenefits2" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_gpLetter2"><h3>Was a letter or report written to their GP, potential employer or external agency?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_gpLetter2" id="cp_gpLetter2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_functionalCapacity"><h3>Did they have a functional capacity assessment?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_functionalCapacity" id="cp_functionalCapacity"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy2"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy2" id="cp_completedBy2" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date2"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date2" id="cp_date2" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time2"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time2" id="cp_Time2" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="2"> <h1>Anterior Cruciate Ligament Reconstruction - Initial Assessment</h1> <div class="row"> <div class="col-sm-6"> <label for="cp_pc"><h3>PC:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_pc" id="cp_pc" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_operationsDate"><h3>Operation date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_operationsDate" id="cp_operationsDate" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_additionalProcedures"><h3>Additional Procedures:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_additionalProcedures" id="cp_additionalProcedures" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_consultant"><h3>Consultant:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_consultant" id="cp_consultant" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_additionalPostOpInstructions"><h3>Additional Post-Op Instructions:</h3></label> <textarea class="form-control" name="cp_additionalPostOpInstructions" id="cp_additionalPostOpInstructions" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_preInjuryPlay"><h3>Does the patient intend to return to pre-injury level of play?</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_preInjuryPlay" id="cp_preInjuryPlay"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_hpc"><h3>HPC:</h3></label> <textarea class="form-control" name="cp_hpc" id="cp_hpc" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_protocol"><h3>Protocol: </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_protocol" id="cp_protocol"> <option value="--">Select</option> <option value="Hamstring Graft ">Hamstring Graft </option> <option value="Patella Graft">Patella Graft</option> <option value="ACL + Meniscal Repair">ACL + Meniscal Repair</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_pmh"><h3>PMH:</h3></label> <textarea class="form-control" name="cp_pmh" id="cp_pmh" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_hxCa"><h3>Hx of Ca:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_hxCa" id="cp_hxCa"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_smoker"><h3>Smoker:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_smoker" id="cp_smoker"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_previousInjury"><h3>Previous Injuries/Operations:</h3></label> <textarea class="form-control" name="cp_previousInjury" id="cp_previousInjury" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherThreads"><h3>DH:</h3></label> <textarea class="form-control" name="cp_otherThreads" id="cp_otherThreads" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_sh"><h3>SH:</h3></label> <textarea class="form-control" name="cp_sh" id="cp_sh" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_mobility"><h3>Mobility:</h3></label> <textarea class="form-control" name="cp_mobility" id="cp_mobility" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_observationPalpation8"><h3>Observation and Palpation:</h3></label> <textarea class="form-control" name="cp_observationPalpation8" id="cp_observationPalpation8" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>VAS Score:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_VASmin"><h3>Min:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_VASmin" id="cp_VASmin" class="form-control"></input>/10 </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_VASmax"><h3>Max:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_VASmax" id="cp_VASmax" class="form-control"></input>/10 </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_MidKnee"><h3>Mid knee:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_MidKnee" id="cp_MidKnee" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_abovePatella"><h3>Above patella:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_abovePatella" id="cp_abovePatella" class="form-control" style="width: 100%;"></input> </div> </div> <h2>AROM:</h2> <div class="row"> <div class="col-sm-4"> <label for="cp_flex"><h3>Flex:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_flexL" id="cp_flexL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_flexR" id="cp_flexR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_ext"><h3>Ext:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_extL" id="cp_extL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_extR" id="cp_extR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_strength"><h3>Strength:</h3></label> <textarea class="form-control" name="cp_strength" id="cp_strength" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_sq"><h3>SQ:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_sqL" id="cp_sqL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_sqR" id="cp_sqR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_slr"><h3>SLR:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_slrL" id="cp_slrL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_slrR" id="cp_slrR" maxlength="15" class="form-control"></input> </div> </div> <h2>Rx:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_oedemaManagemnent1"><h3>Oedema management</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_oedemaManagemnent1" id="cp_oedemaManagemnent"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_rxStage1"><h3>HEP:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="checkbox" id="Rx1_1" name="Rx1_1" value="SQ"> SQ</input><br /> <input type="checkbox" id="Rx1_2" name="Rx1_2" value="SLR"> SLR</input><br /> <input type="checkbox" id="Rx1_3" name="Rx1_3" value="Knee Flexion"> Knee Flexion</input><br /> <input type="checkbox" id="Rx1_4" name="Rx1_4" value="Extension"> Extension</input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherRx1"><h3>Other:</h3></label> <textarea class="form-control" name="cp_otherRx1" id="cp_otherRx1" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_plan1"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_plan1" id="cp_plan1" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuation1"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuation1" id="cp_continuation1" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy3"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy3" id="cp_completedBy3" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date3"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date3" id="cp_date3" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time3"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time3" id="cp_Time3" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="3"> <h1>Anterior Cruciate Ligament Reconstruction - Stage 2 Assessment</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective" id="cp_subjective" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_postOpWeek"><h3>Post-op week:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_postOpWeek" id="cp_postOpWeek" class="form-control"></input>/52 </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_observationPalpation_2"><h3>Observation and Palpation:</h3></label> <textarea class="form-control" name="cp_observationPalpation_2" id="cp_observationPalpation_2" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>AROM:</h2> <div class="row"> <div class="col-sm-4"> <label for="cp_flex2"><h3>Flex:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_flexL2" id="cp_flexL2" maxlength="15" class="form-control"></input> R <input type="text" name="cp_flexR2" id="cp_flexR2" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_ext2"><h3>Ext:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_extL2" id="cp_extL2" maxlength="15" class="form-control"></input> R <input type="text" name="cp_extR2" id="cp_extR2" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_strength2"><h3>Strength:</h3></label> <textarea class="form-control" name="cp_strength2" id="cp_strength2" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_sq2"><h3>SQ:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_sqL2" id="cp_sqL2" maxlength="15" class="form-control"></input> R <input type="text" name="cp_sqR2" id="cp_sqR2" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_slr2"><h3>SLR:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_slrL2" id="cp_slrL2" maxlength="15" class="form-control"></input> R <input type="text" name="cp_slrR2" id="cp_slrR2" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_mobility2"><h3>Mobility</h3></label> <textarea class="form-control" name="cp_mobility2" id="cp_mobility2" rows="10" style="width: 100%;"></textarea> </div> </div> <h1>Stage 2 Criteria </h1> <h2>ACL with Hamstring Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_Flexion100"><h3>Flexion 100:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_Flexion100" id="cp_Flexion100"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_fwbAids"><h3>FWB +/- aids:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fwbAids" id="cp_fwbAids"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>ACL with Patella Tendon Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_flexion90"><h3>Flexion 90:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_flexion90" id="cp_flexion90"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_fwbAids_2"><h3>FWB +/- aids:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fwbAids_2" id="cp_fwbAids_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>ACL + Meniscal Repair:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_flexion902"><h3>Flexion 90:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_flexion902" id="cp_flexion902"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_flexion90_2"><h3>Flexion 90:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_flexion90_2" id="cp_flexion90_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_fwbAids_3"><h3>FWB +/- aids:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fwbAids_3" id="cp_fwbAids_3"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherStage2"><h3>Other:</h3></label> <textarea class="form-control" name="cp_otherStage2" id="cp_otherStage2" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>Rx:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_stage2Exercises"><h3>Stage 2 exercises</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_stage2Exercises" id="cp_stage2Exercises"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_advice"><h3>Advice:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_advice" id="cp_advice"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_oedemaManagemnent"><h3>Oedema management</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_oedemaManagemnent" id="cp_oedemaManagemnent"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_weanWalkingAid"><h3>Wean from walking aid</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_weanWalkingAid" id="cp_weanWalkingAid"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherRx2"><h3>Other:</h3></label> <textarea class="form-control" name="cp_otherRx2" id="cp_otherRx2" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_plan2"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_plan2" id="cp_plan2" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuation2"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuation2" id="cp_continuation2" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy4"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy4" id="cp_completedBy4" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date4"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date4" id="cp_date4" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time4"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time4" id="cp_Time4" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="4"> <h1> Anterior Cruciate Ligament Reconstruction - Stage 3a Assessment</h1><div class="row"> <div class="col-sm-12"> <label for="cp_subjective3"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective3" id="cp_subjective3" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_postOpWeek3"><h3>Post-op week:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_postOpWeek3" id="cp_postOpWeek3" class="form-control"></input>/52 </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_observationPalpation3"><h3>Observation and Palpation:</h3></label> <textarea class="form-control" name="cp_observationPalpation3" id="cp_observationPalpation3" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_OTreferral"><h3>OT referral</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_OTreferral" id="cp_OTreferral"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_reviewDate"><h3>Review Date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_reviewDate" id="cp_reviewDate" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <h2>AROM:</h2> <div class="row"> <div class="col-sm-4"> <label for="cp_flexStage3a"><h3>Flex:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_flexStage3aL" id="cp_flexStageaL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_flexStage3aR" id="cp_flexStage3aR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_extStage3a"><h3>Ext:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_extStage3aL" id="cp_extStage3aL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_extStage3aR" id="cp_extStage3aR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_strengthStage3a"><h3>Strength:</h3></label> <textarea class="form-control" name="cp_strengthStage3a" id="cp_strengthStage3a" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_sqStage3a"><h3>SQ:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_sqStage3aL" id="cp_sqStage3aL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_sqStage3aR" id="cp_sqStage3aR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_slrStagea"><h3>SLR:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_slrStage3aL" id="cp_slrStage3aL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_slrStage3aR" id="cp_slrStage3aR" maxlength="15" class="form-control"></input> </div> </div> <h1>Stage 3a Criteria </h1> <h2>ACL with Hamstring Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_rom0110"><h3>ROM 0-110:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rom0110" id="cp_rom0110"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_fwbNoAids"><h3>FWB - no aids:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fwbNoAids" id="cp_fwbNoAids"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_SLRnoLag"><h3>SLR (no lag):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_SLRnoLag" id="cp_SLRnoLag"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>ACL with Patella Tendon Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_rom0100"><h3>ROM 0-100:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rom0100" id="cp_rom0100"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_fwbNoAids2"><h3>FWB - no aids:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fwbNoAids2" id="cp_fwbNoAids2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slrNoLag2"><h3>SLR (no lag):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slrNoLag2" id="cp_slrNoLag2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>ACL + Meniscal Repair:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_rom090"><h3>ROM 0-90:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rom090" id="cp_rom090"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_fwbNoAids3"><h3>FWB - no aids:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fwbNoAids3" id="cp_fwbNoAids3"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slrNoLag3"><h3>SLR (no lag):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slrNoLag3" id="cp_slrNoLag3"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherStage3"><h3>Other:</h3></label> <textarea class="form-control" name="cp_otherStage3" id="cp_otherStage3" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>Rx:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_stage3aExercises"><h3>Stage 3a exercises</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_stage3aExercises" id="cp_stage3aExercises"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_oedemaManagemnent3"><h3>Oedema management</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_oedemaManagemnent3" id="cp_oedemaManagemnent3"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherStage3a"><h3>Other:</h3></label> <textarea class="form-control" name="cp_otherStage3a" id="cp_otherStage3a" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_planStage3a"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_planStage3a" id="cp_planStage3a" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuationStage3a"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuationStage3a" id="cp_continuationStage3a" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy5"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy5" id="cp_completedBy5" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date5"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date5" id="cp_date5" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time5"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time5" id="cp_Time5" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="5"> <h1> Anterior Cruciate Ligament Reconstruction - Stage 3b Assessment</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective3_2"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective3b" id="cp_subjective3b" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_postOpWeek3_2"><h3>Post-op week:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_postOpWeek3_2" id="cp_postOpWeek3_2" class="form-control"></input>/52 </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_observationPalpation3b"><h3>Observation and Palpation:</h3></label> <textarea class="form-control" name="cp_observationPalpation3b" id="cp_observationPalpation3b" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>AROM:</h2> <div class="row"> <div class="col-sm-4"> <label for="cp_flexStage3b"><h3>Flex:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_flexStage3bL" id="cp_flexStagebL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_flexStage3bR" id="cp_flexStage3bR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_extStage3b"><h3>Ext:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_extStage3bL" id="cp_extStage3bL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_extStage3bR" id="cp_extStage3bR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_strengthStage3b"><h3>Strength:</h3></label> <textarea class="form-control" name="cp_strengthStage3b" id="cp_strengthStage3b" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_sqStage3b"><h3>SQ:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_sqStage3bL" id="cp_sqStage3bL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_sqStage3bR" id="cp_sqStage3bR" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_slrStageb"><h3>SLR:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_slrStage3bL" id="cp_slrStage3bL" maxlength="15" class="form-control"></input> R <input type="text" name="cp_slrStage3bR" id="cp_slrStage3bR" maxlength="15" class="form-control"></input> </div> </div> <h1>Stage 3b Criteria</h1> <h2>ACL with Hamstring Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_rom0120"><h3>ROM 0-120:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rom0120" id="cp_rom0120"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slbalance10s"><h3>SL balance 10s:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slbalance10s" id="cp_slbalance10s"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_gluteBridges"><h3>Glute Bridges x 10:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_gluteBridges" id="cp_gluteBridges"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_hamstringBridge"><h3>Hamstring Bridge x 10:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_hamstringBridge" id="cp_hamstringBridge"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>ACL with Patella Tendon Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_rom0115"><h3>ROM 0-115:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rom0115" id="cp_rom0115"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slBalance10s_2"><h3>SL balance 10s:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slBalance10s_2" id="cp_slBalance10s_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_gluteBridges_2"><h3>Glute Bridges x 10:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_gluteBridges_2" id="cp_gluteBridges_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_hamstringBridge_2"><h3>Hamstring Bridge x 10:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_hamstringBridge_2" id="cp_hamstringBridge_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>ACL + Meniscal Repair:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_rom0903b"><h3>ROM 0-90:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rom0903b" id="cp_rom0903b"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slBalance10s_3"><h3>SL balance 10s:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slBalance10s_3" id="cp_slBalance10s_3"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_gluteBridges3"><h3>Glute Bridges x 10:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_gluteBridges3" id="cp_gluteBridges3"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_hamstringBridge3"><h3>Hamstring Bridge x 10:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_hamstringBridge3" id="cp_hamstringBridge3"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Stage3bRx"><h3>Rx:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_Stage3bRx" id="cp_Stage3bRx"> <option value="--">Select</option> <option value="Stage 3b exercises">Stage 3b exercises</option> <option value="Other">Other</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherStage3b"><h3>Other:</h3></label> <textarea class="form-control" name="cp_otherStage3b" id="cp_otherStage3b" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_planStage3b"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_planStage3b" id="cp_planStage3b" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuationStage3b"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuationStage3b" id="cp_continuationStage3b" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy6"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy6" id="cp_completedBy6" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date6"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date6" id="cp_date6" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time6"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time6" id="cp_Time6" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="6"> <h1>Anterior Cruciate Ligament Reconstruction - Stage 4 Assessment</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective4"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective4" id="cp_subjective4" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_observationPalpation4"><h3>Observation and Palpation:</h3></label> <textarea class="form-control" name="cp_observationPalpation4" id="cp_observationPalpation4" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>AROM:</h2> <div class="row"> <div class="col-sm-4"> <label for="cp_flex4"><h3>Flex:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_flexL4" id="cp_flexL4" maxlength="15" class="form-control"></input> R <input type="text" name="cp_flexR4" id="cp_flexR4" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_ext4"><h3>Ext:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_extL4" id="cp_extL4" maxlength="15" class="form-control"></input> R <input type="text" name="cp_extR4" id="cp_extR4" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_strength4"><h3>Strength:</h3></label> <textarea class="form-control" name="cp_strength4" id="cp_strength4" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_sq4"><h3>SQ:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_sqL4" id="cp_sqL4" maxlength="15" class="form-control"></input> R <input type="text" name="cp_sqR4" id="cp_sqR4" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_slr4"><h3>SLR:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_slrL4" id="cp_slrL4" maxlength="15" class="form-control"></input> R <input type="text" name="cp_slrR4" id="cp_slrR4" maxlength="15" class="form-control"></input> </div> </div> <h1>Stage 4 Criteria</h1> <h2>ACL with Hamstring Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_fullArom"><h3>Full AROM:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fullArom" id="cp_fullArom"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slBalance10sTrampette"><h3>SL balance 10s (trampette):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slBalance10sTrampette" id="cp_slBalance10sTrampette"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_stepUpDown"><h3>Step up/down R=L:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_stepUpDown" id="cp_stepUpDown"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_squat"><h3>Squat (equal WB):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_squat" id="cp_squat"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slrNoLag4"><h3>SLR (no lag):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slrNoLag4" id="cp_slrNoLag4"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>ACL with Patella Tendon Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_fullExtension"><h3>Full Extension:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fullExtension" id="cp_fullExtension"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slBalance10sTrampette4_2"><h3>SL balance 10s (trampette):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slBalance10sTrampette4_2" id="cp_slBalance10sTrampette4_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_stepUpDown4_2"><h3>Step up/down R=L:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_stepUpDown4_2" id="cp_stepUpDown4_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_squat4_2"><h3>Squat (equal WB):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_squat4_2" id="cp_squat4_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slrNoLag4_2"><h3>SLR (no lag):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slrNoLag4_2" id="cp_slrNoLag4_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_aclMeniscalRepair"><h2>ACL + Meniscal Repair:</h2></label> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_rom0904_2"><h3>ROM 0-90:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_rom0904_2" id="cp_rom0904_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slBalance10sTrampette4_3"><h3>SL balance 10s (trampette):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slBalance10sTrampette4_3" id="cp_slBalance10sTrampette4_3"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_stepUpRL"><h3>Step up R=L:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_stepUpRL" id="cp_stepUpRL"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Stage4Rx"><h3>Rx:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_Stage4Rx" id="cp_Stage4Rx"> <option value="--">Select</option> <option value="Stage 4 exercises">Stage 4 exercises</option> <option value="Early Leg Class ">Early Leg Class </option> <option value="Other">Other</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherStage4"><h3>Other:</h3></label> <textarea class="form-control" name="cp_otherStage4" id="cp_otherStage4" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_planStage4"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_planStage4" id="cp_planStage4" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuationStage4"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuationStage4" id="cp_continuationStage4" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy7"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy7" id="cp_completedBy7" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date7"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date7" id="cp_date7" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time7"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time7" id="cp_Time7" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="7"> <h1>Anterior Cruciate Ligament Reconstruction - Stage 5 Assessment</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective5"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective5" id="cp_subjective5" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_observationPalpation5"><h3>Observation and Palpation:</h3></label> <textarea class="form-control" name="cp_observationPalpation5" id="cp_observationPalpation5" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>AROM:</h2> <div class="row"> <div class="col-sm-4"> <label for="cp_flex5"><h3>Flex:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_flexL5" id="cp_flexL5" maxlength="15" class="form-control"></input> R <input type="text" name="cp_flexR5" id="cp_flexR5" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_ext5"><h3>Ext:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_extL5" id="cp_extL5" maxlength="15" class="form-control"></input> R <input type="text" name="cp_extR5" id="cp_extR5" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_strength5"><h3>Strength:</h3></label> <textarea class="form-control" name="cp_strength5" id="cp_strength5" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_sq5"><h3>SQ:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_sqL5" id="cp_sqL5" maxlength="15" class="form-control"></input> R <input type="text" name="cp_sqR5" id="cp_sqR5" maxlength="15" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-4"> <label for="cp_slr5"><h3>SLR:</h3></label> </div> <div class="col-sm-8" style="margin-top: 15px;"> L <input type="text" name="cp_slrL5" id="cp_slrL5" maxlength="15" class="form-control"></input> R <input type="text" name="cp_slrR5" id="cp_slrR5" maxlength="15" class="form-control"></input> </div> </div> <h1>Stage 5 Criteria </h1> <div class="row"> <div class="col-sm-6"> <label for="cp_aclGraft"><h2>ACL with Hamstring or Patella Tendon Graft:</h2></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_aclGraft" id="cp_aclGraft"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_fullAROM"><h3>Full AROM:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fullAROM" id="cp_fullAROM"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slSts750"><h3>SL STS (750 flex) R=L:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slSts750" id="cp_slSts750"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_aclMeniscalRepair5"><h2>ACL + Meniscal Repair:</h2></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_aclMeniscalRepair5" id="cp_aclMeniscalRepair5"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_flexion905"><h3>Flexion ≥90:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_flexion905" id="cp_flexion905"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_SlSts750Flex"><h3>SL STS (750 flex) R=L:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_SlSts750Flex" id="cp_SlSts750Flex"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Stage5Rx"><h3>Rx:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_Stage5Rx" id="cp_Stage5Rx"> <option value="--">Select</option> <option value="Stage 4 exercises">Stage 5 exercises</option> <option value="Other">Other</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherStage5"><h3>Other:</h3></label> <textarea class="form-control" name="cp_otherStage5" id="cp_otherStage5" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_planStage5"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_planStage5" id="cp_planStage5" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuationStage5"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuationStage5" id="cp_continuationStage5" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy8"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy8" id="cp_completedBy8" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date8"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date8" id="cp_date8" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time8"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time8" id="cp_Time8" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="8"> <h1>Anterior Cruciate Ligament Reconstruction - Stage 6 Assessment</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective6"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective6" id="cp_subjective6" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_observationPalpation6"><h3>Observation and Palpation:</h3></label> <textarea class="form-control" name="cp_observationPalpation6" id="cp_observationPalpation6" rows="10" style="width: 100%;"></textarea> </div> </div> <h1>Stage 6 Criteria (Early impact)</h1> <h2>ACL with Hamstring or Patella Tendon Graft:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_fullAROM6"><h3>Full AROM:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fullAROM6" id="cp_fullAROM6"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_singleLegSquat"><h3>Single leg squat x 10 reps (QASLS 0-1)</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_singleLegSquat" id="cp_singleLegSquat"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_SLlegPress_2"><h3>SL Leg press 3 reps = 100% body weight (0-90)</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_SLlegPress_2" id="cp_SLlegPress_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slSTS90"><h3>SL STS 90 x 10,</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slSTS90" id="cp_slSTS90"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_20SLhamstring"><h3>20 SL Hamstring bridges from elevated surface</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_20SLhamstring" id="cp_20SLhamstring"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_20singleHeelRaises"><h3>20 single leg heel raises</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_20singleHeelRaises" id="cp_20singleHeelRaises"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> <option value="not assessed">not assessed</option> </select> </div> </div> <h2>ACL + Meniscal Repair (No impact for 4 months):</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_flexion130"><h3>Flexion 130:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_flexion130" id="cp_flexion130"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_noPain"><h3>Pain Score</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_noPain" id="cp_noPain"> <option value="--">Select</option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_swelling"><h3>Swelling</h3></label> <textarea class="form-control" name="cp_swelling" id="cp_swelling" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_slSTS90_2"><h3>SL STS (90 0 ):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_slSTS90_2" id="cp_slSTS90_2"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_return12weeks"><h3>Return to running 12 weeks</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_return12weeks" id="cp_return12weeks"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_returnToPlayDiscussed"><h3>Return to play discussed</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_returnToPlayDiscussed" id="cp_returnToPlayDiscussed"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_why"><h3>if no why:</h3></label> <textarea class="form-control" name="cp_why" id="cp_why" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-2"> <label for="cp_Stage6Rx"><h3>Rx:</h3></label> </div> <div class="col-sm-10" style="margin-top: 15px;"> <input type="checkbox" id="Rx6_1" name="Rx6_1" value="Stage 6 exercises"> Stage 6 exercises</input><br /> <input type="checkbox" id="Rx6_2" name="Rx6_2" value="Early Impact exercises"> Early Impact exercises</input><br /> <input type="checkbox" id="Rx6_3" name="Rx6_3" value="Videos sent"> Videos sent</input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_other6"><h3>Other:</h3></label> <textarea class="form-control" name="cp_other6" id="cp_other6" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_plan6"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_plan6" id="cp_plan6" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuation6"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuation6" id="cp_continuation6" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy9"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy9" id="cp_completedBy9" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date9"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date9" id="cp_date9" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time9"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time9" id="cp_Time9" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="9"> <h1>Anterior Cruciate Ligament Reconstruction - Stage 7 (4 months)</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective7"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective7" id="cp_subjective7" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_observationPalpation7"><h3>Observation and Palpation:</h3></label> <textarea class="form-control" name="cp_observationPalpation7" id="cp_observationPalpation7" rows="10" style="width: 100%;"></textarea> </div> </div> <h1>BTE:</h1> <h2>Isometric Knee Ext (60<sup>0</sup>)</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_affectedLimb"><h3>Affected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_affectedLimb" id="cp_affectedLimb" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unaffectedLimb"><h3>Unaffected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_unaffectedLimb" id="cp_unaffectedLimb" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSI"><h3>LSI = affected ÷ unaffected x 100 =</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSI" id="cp_LSI" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_attachedBTE"><h3>See attached BTE results</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_attachedBTE" id="cp_attachedBTE"> <option value="--">Select</option> <option value="Yes">Yes</option> <option value="No">No</option> </select> </div> </div> <h2>Single Leg Hop:</h2> <h4>Hop Distance (measured to heel):</h4> <div class="row"> <div class="col-sm-6"> <label for="cp_affectedLimbAttempts"><h3>Affected limb - Attempts 1, 2 and 3 </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1. <input type="text" name="cp_affectedLimbAttempts1" id="cp_affectedLimbAttempts" class="form-control"></input><br /> Attempt 2. <input type="text" name="cp_affectedLimbAttempts2" id="cp_affectedLimbAttempts" class="form-control"></input><br /> Attempt 3. <input type="text" name="cp_affectedLimbAttempts3" id="cp_affectedLimbAttempts" class="form-control"></input><br /> Attempt average (a) <input type="text" name="cp_affectedLimbAttemptsa" id="cp_affectedLimbAttempts" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unffectedLimbAttempts"><h3>Unaffected limb - Attempts 1, 2 and 3 </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1. <input type="text" name="cp_unffectedLimbAttempts1" id="cp_unffectedLimbAttempts" class="form-control"></input><br /> Attempt 2. <input type="text" name="cp_unffectedLimbAttempts2" id="cp_unffectedLimbAttempts" class="form-control"></input><br /> Attempt 3. <input type="text" name="cp_unffectedLimbAttempts3" id="cp_unffectedLimbAttempts" class="form-control"></input><br /> Attempt average (b) <input type="text" name="cp_affectedLimbAttemptsb" id="cp_affectedLimbAttempts" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSIAverage"><h3>LSI = (a/b)x 100 = </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSIAverage" id="cp_LSIAverage" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_rxStage7"><h3>RX - Progressive impact exercises and load acceptance drills:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="checkbox" id="Rx7_1" name="Rx7_1" value="Stage 7 Exercises taught"> Stage 7 Exercises taught</input><br /> <input type="checkbox" id="Rx7_2" name="Rx7_2" value="Videos sent"> Videos sent</input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_other7"><h3>Other:</h3></label> <textarea class="form-control" name="cp_other7" id="cp_other7" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_plan7"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_plan7" id="cp_plan7" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuation7"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuation7" id="cp_continuation7" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy10"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy10" id="cp_completedBy10" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date10"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date10" id="cp_date10" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time10"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time10" id="cp_Time10" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="10"> <h1>Anterior Cruciate Ligament Reconstruction - Stage 8 (5 months)</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective72"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective72" id="cp_subjective72" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>Return to Plyometrics + Agility Criteria</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_fullAROM8"><h3>Full AROM (inc. hyperextension):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fullAROM8" id="cp_fullAROM8"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_goodStage7"><h3>Good stage 8 exercise technique:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_goodStage7" id="cp_goodStage7"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_rxStage8"><h3>RX</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="checkbox" id="Rx8_1" name="Rx8_1" value="Stage 8 Exercises taught"> Stage 8 Exercises taught</input><br /> <input type="checkbox" id="Rx8_2" name="Rx8_2" value="Videos sent"> Videos sent</input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_other8"><h3>Other:</h3></label> <textarea class="form-control" name="cp_other8" id="cp_other8" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_plan8"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_plan8" id="cp_plan8" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuation8"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuation8" id="cp_continuation8" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy11"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy11" id="cp_completedBy11" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date11"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date11" id="cp_date11" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time11"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time11" id="cp_Time11" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="11"> <h1>Anterior Cruciate Ligament Reconstruction - Stage 9 (6 months)</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective73"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective73" id="cp_subjective73" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>Return to Sport Specific Training Criteria </h2> <div class="row"> <div class="col-sm-6"> <label for="cp_fullPainAROM"><h3>Full Pain Free AROM (not affected by exercise):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fullPainAROM" id="cp_fullPainAROM"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_cardioFitness"><h3>Cardiovascular Fitness Similar to Pre-Injury:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_cardioFitness" id="cp_cardioFitness"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_yBalanceTest"><h3>Y-Balance Test >85%:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_yBalanceTest" id="cp_yBalanceTest"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <h2>Hop Tests:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_singleLegTriple"><h3>Single Leg and Triple Hop Tests - LSI Distance ≥ 85%:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_singleLegTriple" id="cp_singleLegTriple"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_crossOverhop"><h3>Cross-over Hop - Hop Distance ≥ 85%:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_crossOverhop" id="cp_crossOverhop"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unilateralLegPress"><h3>Unilateral leg press (3RM 85%) </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_unilateralLegPress" id="cp_unilateralLegPress"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <h1>Single Leg Hop:</h1> <h2>Single Hop Distance (measured to heel)</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_affectedLimbSingle"><h3>Affected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1 <input type="text" name="cp_affectedLimbSingle1" id="cp_affectedLimbSingle1" class="form-control"></input><br /> Attempt 2 <input type="text" name="cp_affectedLimbSingle2" id="cp_affectedLimbSingle2" class="form-control"></input><br /> Attempt 3 <input type="text" name="cp_affectedLimbSingle3" id="cp_affectedLimbSingle3" class="form-control"></input><br /> Average: a. <input type="text" name="cp_affectedLimbSinglea" id="cp_affectedLimbSinglea" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unaffectedLimbSingle"><h3>Unaffected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1 <input type="text" name="cp_unaffectedLimbSingle1" id="cp_unaffectedLimbSingle1" class="form-control"></input><br /> Attempt 2 <input type="text" name="cp_unaffectedLimbSingle2" id="cp_unaffectedLimbSingle2" class="form-control"></input><br /> Attempt 3 <input type="text" name="cp_unaffectedLimbSingle3" id="cp_unaffectedLimbSingle3" class="form-control"></input><br /> Average: b. <input type="text" name="cp_affectedLimbSingleb" id="cp_affectedLimbSingleb" class="form-control"></input> </div> </div> <h2>Triple Hop Distance (measured to heel)</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_affectedLimbTriple"><h3>Affected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1 <input type="text" name="cp_affectedLimbTriple1" id="cp_affectedLimbTriple1" class="form-control"></input><br /> Attempt 2 <input type="text" name="cp_affectedLimbTriple2" id="cp_affectedLimbTriple2" class="form-control"></input><br /> Attempt 3 <input type="text" name="cp_affectedLimbTriple3" id="cp_affectedLimbTriple3" class="form-control"></input><br /> Average: c. <input type="text" name="cp_affectedLimbTripleC" id="cp_affectedLimbTripleC" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unaffectedLimbTriple"><h3>Unaffected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1 <input type="text" name="cp_unaffectedLimbTriple1" id="cp_unaffectedLimbTriple1" class="form-control"></input><br /> Attempt 2 <input type="text" name="cp_unaffectedLimbTriple2" id="cp_unaffectedLimbTriple2" class="form-control"></input><br /> Attempt 3 <input type="text" name="cp_unaffectedLimbTriple3" id="cp_unaffectedLimbTriple3" class="form-control"></input><br /> Average: d. <input type="text" name="cp_unaffectedLimbTripleD" id="cp_unaffectedLimbTripleD" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSIsingleHop"><h3>LSI Single Hop = (a/b) x 100 = </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSIsingleHop" id="cp_LSIsingleHop" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSItripleHop"><h3>LSI Triple Hop = (c/d) x 100 =</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSItripleHop" id="cp_LSItripleHop" class="form-control" style="width: 100%;"></input> </div> </div> <h1>Crossover Hop:</h1> <h2>Start to Heel Measurement:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_crossoverHopAffected"><h3>Affected:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_crossoverHopAffected" id="cp_crossoverHopAffected" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_crossOverhopUnaffected:"><h3>Unaffected:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_crossOverhopUnaffected" id="cp_crossOverhopUnaffected" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSIStage9"><h3>LSI = affected ÷ unaffected x 100 =</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSIStage9" id="cp_LSIStage9" class="form-control" style="width: 100%;"></input> </div> </div> <h2>Unilateral leg press:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_unilateralLegPressAffected"><h3>Affected:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_unilateralLegPressAffected" id="cp_unilateralLegPressAffected" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unilateralLegPressUnaffected:"><h3>Unaffected:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_unilateralLegPressUnaffected" id="cp_unilateralLegPressUnaffected" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSIStage9unilateral"><h3>LSI = affected ÷ unaffected x 100 =</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSIStage9unilateral" id="cp_LSIStage9unilateral" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_rxStage9"><h3>RX</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="checkbox" id="Rx9_1" name="Rx9_1" value="Sport specific drills"> Sport specific drills</input><br /> <input type="checkbox" id="Rx9_2" name="Rx9_2" value="Videos sent"> Videos sent</input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_other9"><h3>Other:</h3></label> <textarea class="form-control" name="cp_other9" id="cp_other9" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_plan9"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_plan9" id="cp_plan9" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuation9"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuation9" id="cp_continuation9" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy12"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy12" id="cp_completedBy12" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date12"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date12" id="cp_date12" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time12"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time12" id="cp_Time12" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> <div class="cpwhiteBox" id="12"> <h1>Return to Sport (9 month) Assessment</h1> <div class="row"> <div class="col-sm-12"> <label for="cp_subjective12"><h3>Subjective:</h3></label> <textarea class="form-control" name="cp_subjective12" id="cp_subjective12" rows="10" style="width: 100%;"></textarea> </div> </div> <h2>Return to Sport Specific Training Criteria </h2> <div class="row"> <div class="col-sm-6"> <label for="cp_fullPainAROM_12"><h3>Full Pain Free AROM (not affected by exercise):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_fullPainAROM_12" id="cp_fullPainAROM_12"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_cardioFitness_12"><h3>Cardiovascular Fitness Similar to Pre-Injury:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_cardioFitness_12" id="cp_cardioFitness_12"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_yBalanceTest_12"><h3>Y-Balance Test >90%:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_yBalanceTest_12" id="cp_yBalanceTest_12"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <h2>Hop Tests:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_singleLegTriple_12"><h3>Single Leg and Triple Hop Tests - LSI Distance ≥ 90%:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_singleLegTriple_12" id="cp_singleLegTriple_12"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_crossOverhop_12"><h3>Cross-over Hop - LSI Distance ≥ 90%:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_crossOverhop_12" id="cp_crossOverhop_12"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <h2>Strength:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_unilateralLegPress_12"><h3>Unilateral leg press (3RM 90%)</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_unilateralLegPress_12" id="cp_unilateralLegPres_12s"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unilateralLegPress_LSI"><h3>Single Leg Press 3RM (LSI ≥ 90%):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_unilateralLegPress_LSI" id="cp_unilateralLegPres_12s"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_isometricExtension"><h3>Isometric Knee Extension (60o) dynamometer LSI ≥ 90%:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_isometricExtension" id="cp_isometricExtension"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_shortLong"><h3>Short + Long Lever Bridge x 25 (≤ 5 rep difference) (30cm box, hip 450):</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <select class="form-control" name="cp_shortLong" id="cp_shortLong"> <option value="--">Select</option> <option value="yes">yes</option> <option value="no">no</option> <option value="not assessed">not assessed</option> </select> </div> </div> <h1>BTE: </h1> <h2>Isometric Knee Ext (60<sup>0</sup>)</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_bteAffectedLimb"><h3>Affected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_bteAffectedLimb" id="cp_bteAffectedLimb" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_bteUnaffectedLimb"><h3>Unaffected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_bteUnaffectedLimb" id="cp_bteUnaffectedLimb" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSIBTE"><h3>LSI = affected ÷ unaffected x 100 =</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSIBTE" id="cp_LSIBTE" class="form-control" style="width: 100%;"></input> </div> </div> <h2>Bridge:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_shortLeverReps"><h3>Short Lever Reps:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_shortLeverReps" id="cp_shortLeverReps" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_longLeverReps"><h3>Long Lever Reps:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_longLeverReps" id="cp_longLeverReps" class="form-control" style="width: 100%;"></input> </div> </div> <h2>Single Leg Hop:</h2> <h3>Single Hop Distance (measured to heel)</h3> <div class="row"> <div class="col-sm-6"> <label for="cp_affectedLimbSingle_12"><h3>Affected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1 <input type="text" name="cp_affectedLimbSingle1_12" id="cp_affectedLimbSingle1_12" class="form-control"></input><br /> Attempt 2 <input type="text" name="cp_affectedLimbSingle2_12" id="cp_affectedLimbSingle2_12" class="form-control"></input><br /> Attempt 3 <input type="text" name="cp_affectedLimbSingle3_12" id="cp_affectedLimbSingle3_12" class="form-control"></input><br /> Average: a. <input type="text" name="cp_affectedLimbSinglea_12" id="cp_affectedLimbSinglea_12" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unaffectedLimbSingle_12"><h3>Unaffected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1 <input type="text" name="cp_unaffectedLimbSingle1_12" id="cp_unaffectedLimbSingle1_12" class="form-control"></input><br /> Attempt 2 <input type="text" name="cp_unaffectedLimbSingle2_12" id="cp_unaffectedLimbSingle2_12" class="form-control"></input><br /> Attempt 3 <input type="text" name="cp_unaffectedLimbSingle3_12" id="cp_unaffectedLimbSingle3_12" class="form-control"></input><br /> Average: b. <input type="text" name="cp_affectedLimbSingleb_12" id="cp_affectedLimbSingleb_12" class="form-control"></input> </div> </div> <h2>Triple Hop Distance (measured to heel)</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_affectedLimbTriple"><h3>Affected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1 <input type="text" name="cp_affectedLimbTriple1_12" id="cp_affectedLimbTriple1_12" class="form-control"></input><br /> Attempt 2 <input type="text" name="cp_affectedLimbTriple2_12" id="cp_affectedLimbTriple2_12" class="form-control"></input><br /> Attempt 3 <input type="text" name="cp_affectedLimbTriple3_12" id="cp_affectedLimbTriple3_12" class="form-control"></input><br /> Average: c. <input type="text" name="cp_affectedLimbTripleC_12" id="cp_affectedLimbTripleC_12" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unaffectedLimbTriple"><h3>Unaffected Limb</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> Attempt 1 <input type="text" name="cp_unaffectedLimbTriple1_12" id="cp_unaffectedLimbTriple1_12" class="form-control"></input><br /> Attempt 2 <input type="text" name="cp_unaffectedLimbTriple2_12" id="cp_unaffectedLimbTriple2_12" class="form-control"></input><br /> Attempt 3 <input type="text" name="cp_unaffectedLimbTriple3_12" id="cp_unaffectedLimbTriple3_12" class="form-control"></input><br /> Average: d. <input type="text" name="cp_unaffectedLimbTripleD_12" id="cp_unaffectedLimbTripleD_12" class="form-control"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSIsingleHop_12"><h3>LSI Single Hop = (a/b) x 100 = </h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSIsingleHop_12" id="cp_LSIsingleHop_12" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSItripleHop_12"><h3>LSI Triple Hop = (c/d) x 100 =</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSItripleHop_12" id="cp_LSItripleHop_12" class="form-control" style="width: 100%;"></input> </div> </div> <h2>Crossover Hop:</h2> <h3>Start to Heel Measurement:</h3> <div class="row"> <div class="col-sm-6"> <label for="cp_crossoverHopAffected_12"><h3>Affected:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_crossoverHopAffected_12" id="cp_crossoverHopAffected_12" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_crossOverhopUnaffected_12"><h3>Unaffected:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_crossOverhopUnaffected_12" id="cp_crossOverhopUnaffected_12" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSIStage_12"><h3>LSI = affected ÷ unaffected x 100 =</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSIStage_12" id="cp_LSIStage_12" class="form-control" style="width: 100%;"></input> </div> </div> <h2>Unilateral leg press:</h2> <div class="row"> <div class="col-sm-6"> <label for="cp_unilateralLegPressAffected_12"><h3>Affected:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_unilateralLegPressAffected_12" id="cp_unilateralLegPressAffected_12" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_unilateralLegPressUnaffected_12"><h3>Unaffected:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_unilateralLegPressUnaffected_12" id="cp_unilateralLegPressUnaffected_12" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_LSIStage9unilateral_12"><h3>LSI = affected ÷ unaffected x 100 =</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_LSIStage9unilateral_12" id="cp_LSIStage9unilateral_12" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_otherStage_12"><h3>Other</h3></label> <textarea class="form-control" name="cp_otherStage_12" id="cp_otherStage_12" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_rxStage_12_2"><h3>Rx:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="checkbox" id="Rx10_1" name="Rx10_1" value="Return to sport advice"> Return to sport advice</input> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_other10"><h3>Other:</h3></label> <textarea class="form-control" name="cp_other10" id="cp_other10" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_plan10"><h3>Plan:</h3></label> <textarea class="form-control" name="cp_plan10" id="cp_plan10" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-12"> <label for="cp_continuation10"><h3>Continuation:</h3></label> <textarea class="form-control" name="cp_continuation10" id="cp_continuation10" rows="10" style="width: 100%;"></textarea> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_completedBy13"><h3>Completed by:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="text" name="cp_completedBy13" id="cp_completedBy13" class="form-control" style="width: 100%;"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_date13"><h3>Review date:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="date" name="cp_date13" id="cp_date13" class="form-control" placeholder="dd/mm/yyyy"></input> </div> </div> <div class="row"> <div class="col-sm-6"> <label for="cp_Time13"><h3>Review time:</h3></label> </div> <div class="col-sm-6" style="margin-top: 15px;"> <input type="time" name="cp_Time13" id="cp_Time13" class="form-control" style="width: 100%;"></input> </div> </div> </div> <a href="#top" class="btn arrow btn-primary" title="Back to Top" alt="Click here to return to the Table of Contents">Back to Top</a> </div>

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