ACL Reconstruction Care Plan

1 What’s contained in a PKB care plan?
2 Long care plan template
3 ACL Reconstruction Proforma Care Plan Template

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

.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>

<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>

<h1>Screening/Consent Checklist Tool, Physiotherapy OPD/Group Rehabilitation London Road Community Hospital (UHDB Trust)</h1>

<h2>1 Consultation Types</h2>

<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>

<label for="cp_consultType"><h3>Patient choice of consultation</h3></label>

</div>

<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>

<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>

<label for="cp_highTemp"><h3>High Temperature</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_contCough"><h3>New continuous cough</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_tasteChange"><h3>Change in taste/smell </h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>3 Covid-19 Risk Screening</h2>

<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>

<option value="--">Select</option>

</select>

</div>

<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>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

<option value="Have none of the above">Have none of the above</option>

</select>

</div>

<h2>4 Informed Consent:</h2>

<h3>(a) Infection Control/Risk with Covid-19</h3>

<p>Explain the safety and infection control measures in place to minimise risk with a F2F consultation.</p>

<label for="cp_infectionUnderstand"><h3>Select to confirm understood</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<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>

<p>Explain the risks of contracting Covid-19</p>

<label for="cp_covidUnderstand"><h3>Select to confirm understood</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<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>

<h3>(b) Clinical Risk/informed choice</h3>

<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>

<option value="--">Select</option>

</select>

</div>

<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>

<option value="--">Select</option>

</select>

</div>

<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>

<option value="--">Select</option>

</select>

</div>

<h3>(c) Questions or Concerns</h3>

<label for="cp_q4Concerns"><h3>Do you have any questions or concerns? </h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_q4concernsAddressed"><h3>Have the questions/concerns been addressed? </h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<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>

<label for="cp_completedBy1"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date1"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time1"><h3>Review time:</h3></label>

</div>

</div>

<h1>Occupational Therapy Assessment</h1>

<h2>Employment details</h2>

<label for="cp_occupation"><h3>Occupation:</h3></label>

</div>

</div>

<label for="cp_employer"><h3>Employer:</h3></label>

</div>

</div>

<label for="cp_shiftPattern"><h3>Normal hours/shift pattern:</h3></label>

</div>

</div>

<label for="cp_jobDescription"><h3>Description of job role:</h3></label>

</div>

<label for="cp_dutiesAvailable"><h3>Potential light duties available:</h3></label>

</div>

<label for="cp_absenceStart"><h3>Start of sickness absence date:</h3></label>

</div>

</div>

<label for="cp_noteExpiry"><h3>Sick note/fit note expiry date:</h3></label>

</div>

</div>

<label for="cp_returnDate"><h3>Any plan/date for return to work:</h3></label>

</div>

</div>

<h3>If employed:</h3>

<label for="cp_dueToInjury"><h3>Is it due to their condition/ injury?</h3></label>

</div>

</div>

<label for="cp_lastEmployed"><h3>When were they last employed?</h3></label>

</div>

</div>

<label for="cp_previousEmployType"><h3>Type of previous employment:</h3></label>

</div>

</div>

<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>

</div>

<label for="cp_sickBenefits"><h3>Sick pay/benefits:</h3></label>

</div>

<label for="cp_initialAdvice"><h3>Any initial advice provided by OT:</h3></label>

</div>

<h2>Discharge assessment</h2>

<h3>Working Patients:</h3>

<label for="cp_rtw"><h3>Has the patient RTW?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_employedSameCompany"><h3>If YES are they employed by the same company?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_resumeNormalHours"><h3>If YES have they resumed normal hours?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_returnToDuties"><h3>If YES have they returned to normal duties?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_rtwNo"><h3>If NO for what reasons?</h3></label>

</div>

<label for="cp_receiveBenefits"><h3>Is the patient currently in receipt of benefits?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<label for="cp_gpLetter"><h3>Was a letter or report written to their GP or place of work?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_workAssessment"><h3>Did they have a work assessment?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<h3>Non-working Patients:</h3>

<label for="cp_rtwNon"><h3>Has the patient RTW?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_activleySeeking"><h3>If NO are they actively seeking employment?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_whatReason"><h3>If NO for what reasons?</h3></label>

</div>

<label for="cp_receiveBenefits2"><h3>Is the patient currently in receipt of benefits?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<label for="cp_gpLetter2"><h3>Was a letter or report written to their GP, potential employer or external agency?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_functionalCapacity"><h3>Did they have a functional capacity assessment?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_completedBy2"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date2"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time2"><h3>Review time:</h3></label>

</div>

</div>

<h1>Anterior Cruciate Ligament Reconstruction - Initial Assessment</h1>

</div>

</div>

<label for="cp_operationsDate"><h3>Operation date:</h3></label>

</div>

</div>

<label for="cp_additionalProcedures"><h3>Additional Procedures:</h3></label>

</div>

</div>

<label for="cp_consultant"><h3>Consultant:</h3></label>

</div>

</div>

<label for="cp_additionalPostOpInstructions"><h3>Additional Post-Op Instructions:</h3></label>

</div>

<label for="cp_preInjuryPlay"><h3>Does the patient intend to return to pre-injury level of play?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<label for="cp_protocol"><h3>Protocol: </h3></label>

</div>

<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>

<option value="--">Select</option>

</select>

</div>

<label for="cp_smoker"><h3>Smoker:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_previousInjury"><h3>Previous Injuries/Operations:</h3></label>

</div>

</div>

</div>

<label for="cp_mobility"><h3>Mobility:</h3></label>

</div>

<label for="cp_observationPalpation8"><h3>Observation and Palpation:</h3></label>

</div>

<h2>VAS Score:</h2>

</div>

<input type="text" name="cp_VASmin" id="cp_VASmin" class="form-control"></input>/10

</div>

</div>

<input type="text" name="cp_VASmax" id="cp_VASmax" class="form-control"></input>/10

</div>

</div>

</div>

<label for="cp_abovePatella"><h3>Above patella:</h3></label>

</div>

</div>

</div>

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>

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>

<label for="cp_strength"><h3>Strength:</h3></label>

</div>

</div>

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>

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>

<label for="cp_oedemaManagemnent1"><h3>Oedema management</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<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>

<label for="cp_otherRx1"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuation1"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy3"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date3"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time3"><h3>Review time:</h3></label>

</div>

</div>

<h1>Anterior Cruciate Ligament Reconstruction - Stage 2 Assessment</h1>

<label for="cp_subjective"><h3>Subjective:</h3></label>

</div>

</div>

<input type="text" name="cp_postOpWeek" id="cp_postOpWeek" class="form-control"></input>/52

</div>

<label for="cp_observationPalpation_2"><h3>Observation and Palpation:</h3></label>

</div>

</div>

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>

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>

<label for="cp_strength2"><h3>Strength:</h3></label>

</div>

</div>

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>

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>

<label for="cp_mobility2"><h3>Mobility</h3></label>

</div>

<h1>Stage 2 Criteria </h1>

<h2>ACL with Hamstring Graft:</h2>

<label for="cp_Flexion100"><h3>Flexion 100:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>ACL with Patella Tendon Graft:</h2>

<label for="cp_flexion90"><h3>Flexion 90:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>ACL + Meniscal Repair:</h2>

<label for="cp_flexion902"><h3>Flexion 90:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_flexion90_2"><h3>Flexion 90:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_otherStage2"><h3>Other:</h3></label>

</div>

<label for="cp_stage2Exercises"><h3>Stage 2 exercises</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_advice"><h3>Advice:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_oedemaManagemnent"><h3>Oedema management</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_weanWalkingAid"><h3>Wean from walking aid</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_otherRx2"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuation2"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy4"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date4"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time4"><h3>Review time:</h3></label>

</div>

</div>

<h1> Anterior Cruciate Ligament Reconstruction - Stage 3a Assessment</h1><div class="row">

<label for="cp_subjective3"><h3>Subjective:</h3></label>

</div>

</div>

<input type="text" name="cp_postOpWeek3" id="cp_postOpWeek3" class="form-control"></input>/52

</div>

<label for="cp_observationPalpation3"><h3>Observation and Palpation:</h3></label>

</div>

<label for="cp_OTreferral"><h3>OT referral</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_reviewDate"><h3>Review Date:</h3></label>

</div>

</div>

</div>

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>

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>

<label for="cp_strengthStage3a"><h3>Strength:</h3></label>

</div>

</div>

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>

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>

<h1>Stage 3a Criteria </h1>

<h2>ACL with Hamstring Graft:</h2>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>ACL with Patella Tendon Graft:</h2>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>ACL + Meniscal Repair:</h2>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_otherStage3"><h3>Other:</h3></label>

</div>

<label for="cp_stage3aExercises"><h3>Stage 3a exercises</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_oedemaManagemnent3"><h3>Oedema management</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_otherStage3a"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuationStage3a"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy5"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date5"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time5"><h3>Review time:</h3></label>

</div>

</div>

<h1> Anterior Cruciate Ligament Reconstruction - Stage 3b Assessment</h1>

<label for="cp_subjective3_2"><h3>Subjective:</h3></label>

</div>

</div>

<input type="text" name="cp_postOpWeek3_2" id="cp_postOpWeek3_2" class="form-control"></input>/52

</div>

<label for="cp_observationPalpation3b"><h3>Observation and Palpation:</h3></label>

</div>

</div>

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>

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>

<label for="cp_strengthStage3b"><h3>Strength:</h3></label>

</div>

</div>

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>

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>

<h1>Stage 3b Criteria</h1>

<h2>ACL with Hamstring Graft:</h2>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_slbalance10s"><h3>SL balance 10s:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_gluteBridges"><h3>Glute Bridges x 10:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_hamstringBridge"><h3>Hamstring Bridge x 10:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>ACL with Patella Tendon Graft:</h2>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_slBalance10s_2"><h3>SL balance 10s:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_gluteBridges_2"><h3>Glute Bridges x 10:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_hamstringBridge_2"><h3>Hamstring Bridge x 10:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>ACL + Meniscal Repair:</h2>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_slBalance10s_3"><h3>SL balance 10s:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_gluteBridges3"><h3>Glute Bridges x 10:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_hamstringBridge3"><h3>Hamstring Bridge x 10:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

<option value="Stage 3b exercises">Stage 3b exercises</option>

<option value="Other">Other</option>

</select>

</div>

<label for="cp_otherStage3b"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuationStage3b"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy6"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date6"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time6"><h3>Review time:</h3></label>

</div>

</div>

<h1>Anterior Cruciate Ligament Reconstruction - Stage 4 Assessment</h1>

<label for="cp_subjective4"><h3>Subjective:</h3></label>

</div>

<label for="cp_observationPalpation4"><h3>Observation and Palpation:</h3></label>

</div>

</div>

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>

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>

<label for="cp_strength4"><h3>Strength:</h3></label>

</div>

</div>

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>

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>

<h1>Stage 4 Criteria</h1>

<h2>ACL with Hamstring Graft:</h2>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_slBalance10sTrampette"><h3>SL balance 10s (trampette):</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_squat"><h3>Squat (equal WB):</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>ACL with Patella Tendon Graft:</h2>

<label for="cp_fullExtension"><h3>Full Extension:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_slBalance10sTrampette4_2"><h3>SL balance 10s (trampette):</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_squat4_2"><h3>Squat (equal WB):</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_aclMeniscalRepair"><h2>ACL + Meniscal Repair:</h2></label>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_slBalance10sTrampette4_3"><h3>SL balance 10s (trampette):</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<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>

<label for="cp_otherStage4"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuationStage4"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy7"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date7"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time7"><h3>Review time:</h3></label>

</div>

</div>

<h1>Anterior Cruciate Ligament Reconstruction - Stage 5 Assessment</h1>

<label for="cp_subjective5"><h3>Subjective:</h3></label>

</div>

<label for="cp_observationPalpation5"><h3>Observation and Palpation:</h3></label>

</div>

</div>

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>

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>

<label for="cp_strength5"><h3>Strength:</h3></label>

</div>

</div>

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>

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>

<h1>Stage 5 Criteria </h1>

<label for="cp_aclGraft"><h2>ACL with Hamstring or Patella Tendon Graft:</h2></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_aclMeniscalRepair5"><h2>ACL + Meniscal Repair:</h2></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_flexion905"><h3>Flexion ≥90:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

<option value="Stage 4 exercises">Stage 5 exercises</option>

<option value="Other">Other</option>

</select>

</div>

<label for="cp_otherStage5"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuationStage5"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy8"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date8"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time8"><h3>Review time:</h3></label>

</div>

</div>

<h1>Anterior Cruciate Ligament Reconstruction - Stage 6 Assessment</h1>

<label for="cp_subjective6"><h3>Subjective:</h3></label>

</div>

<label for="cp_observationPalpation6"><h3>Observation and Palpation:</h3></label>

</div>

<h1>Stage 6 Criteria (Early impact)</h1>

<h2>ACL with Hamstring or Patella Tendon Graft:</h2>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_singleLegSquat"><h3>Single leg squat x 10 reps (QASLS 0-1)</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_SLlegPress_2"><h3>SL Leg press 3 reps = 100% body weight (0-90)</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_20SLhamstring"><h3>20 SL Hamstring bridges from elevated surface</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_20singleHeelRaises"><h3>20 single leg heel raises</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<h2>ACL + Meniscal Repair (No impact for 4 months):</h2>

<label for="cp_flexion130"><h3>Flexion 130:</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_noPain"><h3>Pain Score</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_swelling"><h3>Swelling</h3></label>

</div>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_return12weeks"><h3>Return to running 12 weeks</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_returnToPlayDiscussed"><h3>Return to play discussed</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

</div>

<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>

<label for="cp_other6"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuation6"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy9"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date9"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time9"><h3>Review time:</h3></label>

</div>

</div>

<h1>Anterior Cruciate Ligament Reconstruction - Stage 7 (4 months)</h1>

<label for="cp_subjective7"><h3>Subjective:</h3></label>

</div>

<label for="cp_observationPalpation7"><h3>Observation and Palpation:</h3></label>

</div>

<h2>Isometric Knee Ext (60<sup>0</sup>)</h2>

<label for="cp_affectedLimb"><h3>Affected Limb</h3></label>

</div>

</div>

<label for="cp_unaffectedLimb"><h3>Unaffected Limb</h3></label>

</div>

</div>

<label for="cp_LSI"><h3>LSI = affected ÷ unaffected x 100 =</h3></label>

</div>

</div>

<label for="cp_attachedBTE"><h3>See attached BTE results</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>Single Leg Hop:</h2>

<h4>Hop Distance (measured to heel):</h4>

<label for="cp_affectedLimbAttempts"><h3>Affected limb - Attempts 1, 2 and 3 </h3></label>

</div>

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>

<label for="cp_unffectedLimbAttempts"><h3>Unaffected limb - Attempts 1, 2 and 3 </h3></label>

</div>

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>

<label for="cp_rxStage7"><h3>RX - Progressive impact exercises and load acceptance drills:</h3></label>

</div>

<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>

<label for="cp_other7"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuation7"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy10"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date10"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time10"><h3>Review time:</h3></label>

</div>

</div>

<h1>Anterior Cruciate Ligament Reconstruction - Stage 8 (5 months)</h1>

<label for="cp_subjective72"><h3>Subjective:</h3></label>

</div>

<h2>Return to Plyometrics + Agility Criteria</h2>

<label for="cp_fullAROM8"><h3>Full AROM (inc. hyperextension):</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_goodStage7"><h3>Good stage 8 exercise technique:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

</div>

<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>

<label for="cp_other8"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuation8"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy11"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date11"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time11"><h3>Review time:</h3></label>

</div>

</div>

<h1>Anterior Cruciate Ligament Reconstruction - Stage 9 (6 months)</h1>

<label for="cp_subjective73"><h3>Subjective:</h3></label>

</div>

<h2>Return to Sport Specific Training Criteria </h2>

<label for="cp_fullPainAROM"><h3>Full Pain Free AROM (not affected by exercise):</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_cardioFitness"><h3>Cardiovascular Fitness Similar to Pre-Injury:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_yBalanceTest"><h3>Y-Balance Test >85%:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<h2>Hop Tests:</h2>

<label for="cp_singleLegTriple"><h3>Single Leg and Triple Hop Tests - LSI Distance ≥ 85%:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_crossOverhop"><h3>Cross-over Hop - Hop Distance ≥ 85%:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_unilateralLegPress"><h3>Unilateral leg press (3RM 85%) </h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<h1>Single Leg Hop:</h1>

<h2>Single Hop Distance (measured to heel)</h2>

<label for="cp_affectedLimbSingle"><h3>Affected Limb</h3></label>

</div>

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>

<label for="cp_unaffectedLimbSingle"><h3>Unaffected Limb</h3></label>

</div>

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>

<h2>Triple Hop Distance (measured to heel)</h2>

<label for="cp_affectedLimbTriple"><h3>Affected Limb</h3></label>

</div>

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>

<label for="cp_unaffectedLimbTriple"><h3>Unaffected Limb</h3></label>

</div>

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>

<label for="cp_LSIsingleHop"><h3>LSI Single Hop = (a/b) x 100 = </h3></label>

</div>

</div>

<label for="cp_LSItripleHop"><h3>LSI Triple Hop = (c/d) x 100 =</h3></label>

</div>

</div>

<h1>Crossover Hop:</h1>

<h2>Start to Heel Measurement:</h2>

<label for="cp_crossoverHopAffected"><h3>Affected:</h3></label>

</div>

</div>

<label for="cp_crossOverhopUnaffected:"><h3>Unaffected:</h3></label>

</div>

</div>

<label for="cp_LSIStage9"><h3>LSI = affected ÷ unaffected x 100 =</h3></label>

</div>

</div>

<h2>Unilateral leg press:</h2>

<label for="cp_unilateralLegPressAffected"><h3>Affected:</h3></label>

</div>

</div>

<label for="cp_unilateralLegPressUnaffected:"><h3>Unaffected:</h3></label>

</div>

</div>

<label for="cp_LSIStage9unilateral"><h3>LSI = affected ÷ unaffected x 100 =</h3></label>

</div>

</div>

</div>

<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>

<label for="cp_other9"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuation9"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy12"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date12"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time12"><h3>Review time:</h3></label>

</div>

</div>

<h1>Return to Sport (9 month) Assessment</h1>

<label for="cp_subjective12"><h3>Subjective:</h3></label>

</div>

<h2>Return to Sport Specific Training Criteria </h2>

<label for="cp_fullPainAROM_12"><h3>Full Pain Free AROM (not affected by exercise):</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_cardioFitness_12"><h3>Cardiovascular Fitness Similar to Pre-Injury:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_yBalanceTest_12"><h3>Y-Balance Test >90%:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<h2>Hop Tests:</h2>

<label for="cp_singleLegTriple_12"><h3>Single Leg and Triple Hop Tests - LSI Distance ≥ 90%:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_crossOverhop_12"><h3>Cross-over Hop - LSI Distance ≥ 90%:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<h2>Strength:</h2>

<label for="cp_unilateralLegPress_12"><h3>Unilateral leg press (3RM 90%)</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_unilateralLegPress_LSI"><h3>Single Leg Press 3RM (LSI ≥ 90%):</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_isometricExtension"><h3>Isometric Knee Extension (60o) dynamometer LSI ≥ 90%:</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<label for="cp_shortLong"><h3>Short + Long Lever Bridge x 25 (≤ 5 rep difference) (30cm box, hip 450):</h3></label>

</div>

<option value="--">Select</option>

<option value="not assessed">not assessed</option>

</select>

</div>

<h2>Isometric Knee Ext (60<sup>0</sup>)</h2>

<label for="cp_bteAffectedLimb"><h3>Affected Limb</h3></label>

</div>

</div>

<label for="cp_bteUnaffectedLimb"><h3>Unaffected Limb</h3></label>

</div>

</div>

<label for="cp_LSIBTE"><h3>LSI = affected ÷ unaffected x 100 =</h3></label>

</div>

</div>

<h2>Bridge:</h2>

<label for="cp_shortLeverReps"><h3>Short Lever Reps:</h3></label>

</div>

</div>

<label for="cp_longLeverReps"><h3>Long Lever Reps:</h3></label>

</div>

</div>

<h2>Single Leg Hop:</h2>

<h3>Single Hop Distance (measured to heel)</h3>

<label for="cp_affectedLimbSingle_12"><h3>Affected Limb</h3></label>

</div>

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>

<label for="cp_unaffectedLimbSingle_12"><h3>Unaffected Limb</h3></label>

</div>

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>

<h2>Triple Hop Distance (measured to heel)</h2>

<label for="cp_affectedLimbTriple"><h3>Affected Limb</h3></label>

</div>

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>

<label for="cp_unaffectedLimbTriple"><h3>Unaffected Limb</h3></label>

</div>

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>

<label for="cp_LSIsingleHop_12"><h3>LSI Single Hop = (a/b) x 100 = </h3></label>

</div>

</div>

<label for="cp_LSItripleHop_12"><h3>LSI Triple Hop = (c/d) x 100 =</h3></label>

</div>

</div>

<h2>Crossover Hop:</h2>

<h3>Start to Heel Measurement:</h3>

<label for="cp_crossoverHopAffected_12"><h3>Affected:</h3></label>

</div>

</div>

<label for="cp_crossOverhopUnaffected_12"><h3>Unaffected:</h3></label>

</div>

</div>

<label for="cp_LSIStage_12"><h3>LSI = affected ÷ unaffected x 100 =</h3></label>

</div>

</div>

<h2>Unilateral leg press:</h2>

<label for="cp_unilateralLegPressAffected_12"><h3>Affected:</h3></label>

</div>

</div>

<label for="cp_unilateralLegPressUnaffected_12"><h3>Unaffected:</h3></label>

</div>

</div>

<label for="cp_LSIStage9unilateral_12"><h3>LSI = affected ÷ unaffected x 100 =</h3></label>

</div>

</div>

<label for="cp_otherStage_12"><h3>Other</h3></label>

</div>

</div>

<input type="checkbox" id="Rx10_1" name="Rx10_1" value="Return to sport advice"> Return to sport advice</input>

</div>

<label for="cp_other10"><h3>Other:</h3></label>

</div>

</div>

<label for="cp_continuation10"><h3>Continuation:</h3></label>

</div>

<label for="cp_completedBy13"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date13"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time13"><h3>Review time:</h3></label>

</div>

</div>

</div>