A protocol for permissive weight bearing during allied health therapy in pelvic and the lower extremities fractures 55 Patient profile descriptor Name of patient: Male/Female: Date of birth: Fracture date: Date of surgery: Date screening Systemic Factors Age Informal care in home situation Yes No Osteoporosis Yes No Unknown Nutrition status SNAQ score (Short Nutritional Assessment Questionnaire) No malnutrition Imminent malnutrition Malnutrition Albumin level ………gram/Litre Dehydration Yes No Anaemia Yes No Comorbidity Diabetes Mellitus COPD Chronic Obstructive Pulmonary Disease Cardiac Disease Peripheral Vascular Disease Peripheral Neurological Disease Central Neurological Disease Intoxications/Radiation Smoking No Former Smoker Recent Smoker Alcohol No More than 2 drinks a day Medication Cytostatics Description: Corticosteroids Description: NSAID. Non-Steroidal Anti Inflammatory drugs Description Immunosuppressives Description Radiotherapy near fracture area Yes No Trauma related Intensive care unit stay <48 hours >48 hours >2 weeks Ventilation No Yes /during…….Days High energy trauma Yes No Multi-trauma Yes No Number of fractures ………… Fracture related Fracture 1 Fracture 2 Fracture 3 Fracture…… Complications Description Infection Neurological complication Vascular complication CRPS (Chronic Regional Pain Syndrome) Dislocated fracture parts Non-union Mal-union Delayed union Personal characteristics Depression HADS (Hospital Anxiety and Depression) Depression score Fear HADS (Hospital Anxiety and Depression) Anxiety score Psychopathology indicator SCL 90 (Symptom checklist) multidimensional psychopathology indicator Score Psychological factor influencing return to work VAR (Vragenlijst Arbeids Reïntegratie*) *(Dutch Questionnaire on Return to Work) Score Work (physical workload) Heavy Light Figure 5.3 Patient Assessment Guide.