|
X-ray views taken
• • •
|
|
|
REVIEW OF SYSTEMS
|
|
|
General:Recent weight loss or weight gain
|
Skin: Rashes, hives or lesions
|
|
HEENT: Hay fever or post nasal discharge
|
Cardiovascular: Chest pain or palpitations
|
|
Pulmonary:Shortness of breath/wheezing/coughing
|
Gastrointestinal: Nausea, vomiting,or diarrhea
|
|
Genitourinary: frequency or urgency
|
Lymphatic: lymphadenopathy or polydypsia
|
|
Endocrine: Polyuria or polydypsia
|
Neurological: history of seizures or headache
|
|
Notes
|
|
|
|
|
|
SOCIAL HISTORY
|
|
|
Tobacco usage
|
Alcohol usage
|
|
Drug usage
|
Exercise
|
|
Notes:
|
|
|
INSPECTION
|
|
|
LEFT
• • •
|
RIGHT
• • •
|
|
Notes:
|
|
|
|
|
|
CRANIAL NERVE EXAM
|
|
|
OLFACTORY
|
OPTIC
|
|
OCCULOMOTOR
|
TROCHLEAR
|
|
TRIGEMINAL
|
ABDUCENS
|
|
FACIAL
|
ACOUSTIC
|
|
GLOSSOPHARYNGEAL
|
VAGUS
|
|
SPINAL ACCESSORY
|
HYPOGLOSSAL
|
|
Notes:
|
|
|
|
|
|
Cervical Range of Motion
|
|
|
Flexion
|
Flexion: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Extension
|
Extension: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Left Lateral Flexion
|
Left Lateral Flexion: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right Lateral Flexion
|
Right Lateral Flexion: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Left Rotation
|
Left Rotation: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right Rotation
|
Right Rotation: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
|
|
|
Lumbar Range of Motion
|
|
|
Flexion
|
Flexion: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Extension
|
Extension: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Left Lateral Flexion
|
Left Lateral Flexion: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right Lateral Flexion
|
Right Lateral Flexion: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Left Rotation
|
Left Rotation: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right Rotation
|
Right Rotation: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
|
|
|
Shoulder Range of Motion
|
|
|
Left Flexion
|
Left Flexion: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Left Extension
|
Left Extension: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Left External Rotation
|
Left External Rotation: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Left Internal Rotation
|
Left Internal Rotation : _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Left Abduction
|
Left Abduction: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right Flexion
|
Right Flexion: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right Extension
|
Right Extension: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right External Rotation
|
Right External Rotation: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right Internal Rotation
|
Right Internal Rotation : _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
Right Abduction
|
Right Abduction: _____°
|
|
Active P/NP /Passive P/NP
• • •
|
Notes
|
|
|
|
|
MYOTOME TESTING
|
|
|
Deep Neck Muscles (C1-C4): LEFT
|
RIGHT
|
|
Deltoids (C5): LEFT
|
RIGHT
|
|
Biceps (C6): LEFT
|
RIGHT
|
|
Wrist Extensors (C6): LEFT
|
RIGHT
|
|
Triceps (C7): LEFT
|
RIGHT
|
|
Wrist Flexors (C7): LEFT
|
RIGHT
|
|
Finger Extensors (C7): LEFT
|
RIGHT
|
|
Finger Flexors (C8): LEFT
|
RIGHT
|
|
Finger Adductors (C8-T1): LEFT
|
RIGHT
|
|
Finger Adductors (C8-T1): LEFT
|
RIGHT
|
|
Thumb Abductors (T1): LEFT
|
RIGHT
|
|
Upper Abdomen (T7-T9): LEFT
|
RIGHT
|
|
Lower Abdomen (T10-L1): LEFT
|
RIGHT
|
|
Hip Flexors (L2-L3): LEFT
|
RIGHT
|
|
Leg Extensors (L3-L4): LEFT
|
RIGHT
|
|
Hip Extensors (L4-L5): LEFT
|
RIGHT
|
|
Ankle Dorsiflexion (L4-L5): LEFT
|
RIGHT
|
|
Leg Flexors (L5-S1): LEFT
|
RIGHT
|
|
Ankle Plantarflexion(S1-S2): LEFT
|
RIGHT
|
|
Notes
|
|
|
|
|
|
PAIN SENSATION TESTING
|
|
|
C5
• • •
|
C6
• • •
|
|
C7
• • •
|
C8
• • •
|
|
T1
• • •
|
T2
• • •
|
|
L3
• • •
|
L4
• • •
|
|
L5
• • •
|
S1
• • •
|
|
Notes
|
|
|
|
|
|
NEUROLOGICAL EXAMINATION
|
|
|
DEEP TENDON REFLEXES OF THE UPPER EXTREMITIES
|
|
|
Biceps C5/C6: Left
|
Right
|
|
Brachioradialis C5/C6: Left
|
Right
|
|
Triceps C7/C8: Left
|
Right
|
|
Notes
|
|
|
|
|
|
DEEP TENDON REFLEXES OF THE LOWER EXTREMITIES
|
|
|
Patellar L2/L4: Left
|
Right
|
|
Achilles S1/S2: Left
|
Right
|
|
Notes
|
|
|
|
|
|
PATHOLOGICAL REFLEXES
|
|
|
Upper extremity Hoffman's
|
Lower extremity Babinski
|
|
Tromner’s
|
Notes
|
|
|
|
|
THE PROPRIOCEPTIVE SYSTEM
|
|
|
JOINT POSTION TEST(Eyes closed)
|
Joint(s) Tested:
|
|
VIBRATION TEST(Eyes closed)
|
Joint(s) Tested:
|
|
POINT TO POINT TESTING
|
DYSSYNERGIA:
|
|
DYSDIADOCHOKINESIA:
|
DYSARTHRIA:
|
|
HEEL WALKING :
|
TOE WALKING :
|
|
TANDEM GAIT :
|
NYSTAGMUS :
|
|
ATAXIA
|
ROMBERG TEST: (Eyes closed)
|
|
Notes
|
|
|
|
|
|
ORTHOPEDIC TESTS - CERVICAL REGION
|
|
|
Maximum Compression
• • •
|
with pain radiating into_____
• • •
|
|
Jackson's Compression
• • •
|
with pain radiating into_____
• • •
|
|
Spurling's Compression
• • •
|
with pain radiating into_____
• • •
|
|
Distraction Test
|
Lhermittes Sign
• • •
|
|
Valsalva
|
Bakody's Sign
|
|
Nafziger’s test
|
Vertebral artery screen
|
|
Adson's Test
• • •
|
Eden’ Costoclavicular
• • •
|
|
Shoulder Depression Test
• • •
|
Notes
|
|
|
|
|
ORTHOPEDIC TESTS -BACK, HIP & LOWER LIMB:
|
|
|
Bechterew's Sitting
• • •
|
Valsalva's Maneuver
|
|
Minor's Sign
|
|
|
Kemp's Test
• • •
|
Bowstringing Sign Cram’s
• • •
|
|
Trendelenburg's Test
• • •
|
Notes
|
|
|
|
|
SUPINE
|
|
|
Straight Leg Raise
• • •
|
|
|
Left
|
Right
|
|
Braggard's Sign
• • •
|
Well-Leg Raise
• • •
|
|
Laseque’s
|
Lindner's Sign
|
|
Sicard’s
|
Turyn’s
|
|
Gaenslen’s Test
• • •
|
Fabere Patrick Test
• • •
|
|
Thomas' Test
• • •
|
Notes
|
|
|
|
|
PRONE
|
|
|
Ely's Heel to Buttocks Test
• • •
|
Iliac Compression
• • •
|
|
Yeoman's Test
• • •
|
Hibb's Test
• • •
|
|
Mennell's Test
• • •
|
Notes
|
|
|
|
|
KNEE
|
|
|
Apley's Test
• • •
|
Valgus Stress Test
• • •
|
|
Varus Stress Test
• • •
|
Anterior Drawer Test
• • •
|
|
Posterior Drawer Test
• • •
|
Lauchmann’s Test
• • •
|
|
Patellar Grinding
• • •
|
Patellar Apprehension
• • •
|
|
McMurray's Click Test
• • •
|
Bounce Home
• • •
|
|
Wilson's Test
• • •
|
Notes
|
|
|
|
|
ANKLE AND FOOT
|
|
|
Anterior Foot Draw Test
• • •
|
Homan's Sign
• • •
|
|
Strunsky's Sign
• • •
|
Metatarsal Test
• • •
|
|
Thompson's Test
• • •
|
Notes
|
|
|
|
|
ORTHOPEDIC TESTS -SHOULDER and ELBOW
|
|
|
SHOULDER
|
|
|
Impingement Test
• • •
|
Codman's Test(Drop arm test)
• • •
|
|
Dawbarn's Test
• • •
|
Yergason's Test
|
|
Apley's Scratch Test
|
Dugas
|
|
Supraspinatus Test
|
Speeds
|
|
Mazion
|
Post. Sulcus sign
|
|
Transverse Hum. Lig. Int./ext rot.
|
|
|
Notes
|
|
|
|
|
|
ELBOW
|
|
|
Tennis Elbow Test
|
Golfer’s Elbow Test
|
|
Tinel's Sign
|
Mill's Test
|
|
Valgus Stress Test
|
|
|
Notes
|
|
|
|
|
|
PALPATION
|
|
|
Tenderness on Palpation: RIGHT
• • •
|
LEFT
• • •
|
|
Notes
|
|
|
|
|
|
PARA-VERTEBRAL MUSCLE SPASM/ Trigger points
|
|
|
SPINE
• • •
|
CALF
• • •
|
|
PELVIS
• • •
|
THIGH:
• • •
|
|
Notes
|
|
|
MOTION PALPATION
|
|
|
Segmental Dyskinesia or Dysfunction: RIGHT
• • •
|
LEFT
• • •
|
|
Notes
|
|
