Ankle & Foot Inside Outside Appearance NormalSwellingRednessErythemaDeformityScars Palpation 1. Distal Fibula R L 2. Distal Tibia R L 3. ATFL R L 4. Anterior Aspect of Calcaneous R L 5. Insertion of Achilles R L 6. Other Observed Abnormality? Yes No Sensation Intact? Yes No Moves Extremities w/o Deficit? Yes No Strength - Select - 1 2 3 4 5 Range of Motion Plantar Flexion FullLimited LevelPainExplain Dorsi Flexion FullLimited LevelPainExplain Inversion FullLimited LevelPainExplain Eversion FullLimited LevelPainExplain Procedure Note Consent Skin Cleaned with Chlohexadine Other Tender Points Injected with:Dextrose PRP Joint Injection:Dextrose PRP Stem Cell Resolution of Symptoms? Yes No Tolerated Well? Yes No Procedural Sedation: Medication 1: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 2: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Medication 3: - Select - Ativan Dilaudid Demerol Fentanyl Ketamine Morphine Valium Verscel Dose Δ
