 Initial Exam

 Interim Exam

Examination  Final Exam

Patient Name: ___________________________ Case #: ______________ Date: ___________

VITALS & VASCULAR

Blood Pressure: _____/_____ Pulse _____bpm Respirations _____ /Min Temperature ______ 0F Weight ______
Georges Test + / - DNP Deklyns Test + / - DNP Barre Leiou + / - DNP
SOFT TISSUE EVALUATION
‫ ٱ‬Spasms ‫ ٱ‬Taut & Tender Fibers ‫ ٱ‬Myofascial Trigger Points ‫ ٱ‬Asymmetrical Contractions
Involved Muscles:
MOTION PALPATION
‫ ٱ‬Fixation ‫ ٱ‬Decreased P-A Motion ‫ٱ‬ Decreased Rotation ‫ٱ‬ Restricted Circumduction
Involved Segments:
POSTURE EXAMINATION
Skull: ‫ ٱ‬Forward Head Posture ‫ ٱ‬Rotation R/L ‫ ٱ‬Translation R/L ‫ ٱ‬Lateral Flexion R/L
Thorax: ‫ ٱ‬High Shoulder R/L ‫ ٱ‬Rotation R/L ‫ ٱ‬Translation R/L
Pelvis: ‫ ٱ‬High Hip R/L ‫ ٱ‬Rotation R/L ‫ ٱ‬Translation R/L
SPINAL RANGE OF MOTION
Cervico-Thoracic Norm Tested Pain Thoraco-Lumbar Norm Tested Pain
Flexion 500 Flexion 600
Extension 700 Extension 250
Right Rotation 850 Right Rotation 450
Left Rotation 850 Left Rotation 450
Right Lateral Flexion 450 Right Lateral Flexion 250
Left Lateral Flexion 450 Left Lateral Flexion 250
MOTOR & MUSCLE TESTING NEUROLOGICAL
Shoulder Abduction (C5) R+ L+ DTR: Biceps (C5,6) R+ L+
Wrist Extension (C6) R+ L+ DTR: Triceps (C7,8) R+ L+
Wrist Flexion (C7) R+ L+ DTR: Patellar (L4,5) R+ L+
Finger Abduction (C8) R+ L+ DTR: Achilles (L5,S1) R+ L+
Heel Walk (L5) R+ L+ Dermatomes: ‫ ٱ‬WNL ‫ ٱ‬Abnormal
Toe Walk (S1) R+ L+ ‫ ٱ‬Radiating Pain ‫ ٱ‬Paresthesia ‫ ٱ‬Numbness
Dynanometry: Right Hand Left Hand Comments:
ORTHOPEDIC TESTING
Weight Dist.: L R Gait: ‫ ٱ‬WNL ‫ ٱ‬Abnormal Antalgic Lean: + / - R / L
Foramen Compression +/ - Adam’s Position +R +L Fabere Patrick’s +R +L
Jackson’s +R +L Bechterew’s Sitting Test +R +L Ely-Nachlas +R +L
Cervical Distraction +R +L SLR +R +L Yeoman’s +R +L
Shoulder Depression +R +L WLR +R +L Iliac Compression +R +L
Bakody’s +R +L Braggard’s Sign +R +L Phalen’s +R +L
Valsalva’s +/- Laseque Test +R +L Reverse Phalen’s +R +L
Soto Hall +/- Milgram’s Test +R +L Carpal Compression +R +L
Adson’s +R +L Kemps +R +L Tinnel’s Tap +R +L
Physician’s Signature: ________________________________, D.C.