PHYSICAL EXAMINATION FORM Patient Name



PHYSICAL EXAMINATION FORM Patient Name _____________________________________________

Date__________________ Date___________________

|Exam |Findings |Points |

|FRI |---------- |/40 |

|Limp | |/1 |

|Guarded |M/Mod/S |/3 |

|Antalgic | P |/2 |

|Ant. Head | |/1 |

|Ant. Shoulder Roll |R L B |/2 |

|Head tilt | |/1 |

|Head Rot | |/1 |

|Elevated shoulder | |/1 |

|Scapular retraction | |/1 |

|Elevated hip | |/1 |

|External Foot Flare |R L B |/2 |

|Lumbar Flex |/60 P |/2 |

|Lumbar Ext |/25 P |/2 |

|Lumbar L Lat |/25 P |/2 |

|Lumbar R Lat |/25 P |/2 |

|Kemps |/ |/2 |

|Bicepts Reflex |/ |/2 |

|Patellar Reflex |/ |/2 |

|Bechterew Test |/ |/2 |

|Hamstring Tight |/ |/2 |

|Cervical Flex | /50 P |/2 |

|Cervical Ext | /60 P |/2 |

|Cervical L Lateral | /45 P |/2 |

|Cervical R Lateral | /45P |/2 |

|Cervical L Rot | /80 P |/2 |

|Cervical R Rot | /80 P |/2 |

|Maximal Compress |/ |/2 |

|Shoulder Depress |/ |/2 |

|Soto Hall |/ |/1 |

|Valsalva |/ |/1 |

|DeJerines |/ |/1 |

|SLR |/ |/2 |

|Ely’s |/ |/2 |

|Nachlas |/ |/2 |

|Quad tight |/ |/2 |

|Sacral base fixation |/ |/2 |

|Cervical trg pts | |/10 |

|Thoracic trg pts | |/8 |

|Lumbar trg pts | |/6 |

|Allodenia |/28 |

|R PSIS L PSIS R SI L SI |

|L 5 4 3 2 1 |

|T 12 11 10 9 8 7 6 5 4 3 2 1 |

|C 7 6 5 4 3 2 1 |

|Exam |Findings |Points |

|FRI |---------- |/40 |

|Limp | |/1 |

|Guarded |M/Mod/S |/3 |

|Antalgic | P |/2 |

|Ant. Head | |/1 |

|Ant. Shoulder Roll |R L B |/2 |

|Head tilt | |/1 |

|Head Rot | |/1 |

|Elevated shoulder | |/1 |

|Scapular retraction | |/1 |

|Elevated hip | |/1 |

|External Foot Flare |R L B |/2 |

|Lumbar Flex |/60 P |/2 |

|Lumbar Ext |/25 P |/2 |

|Lumbar L Lat |/25 P |/2 |

|Lumbar R Lat |/25 P |/2 |

|Kemps |/ |/2 |

|Bicepts Reflex |/ |/2 |

|Patellar Reflex |/ |/2 |

|Bechterew Test |/ |/2 |

|Hamstring Tight |/ |/2 |

|Cervical Flex | /50 P |/2 |

|Cervical Ext | /60 P |/2 |

|Cervical L Lateral | /45 P |/2 |

|Cervical R Lateral | /45P |/2 |

|Cervical L Rot | /80 P |/2 |

|Cervical R Rot | /80 P |/2 |

|Maximal Compress |/ |/2 |

|Shoulder Depress |/ |/2 |

|Soto Hall |/ |/1 |

|Valsalva |/ |/1 |

|DeJerines |/ |/1 |

|SLR |/ |/2 |

|Ely’s |/ |/2 |

|Nachlas |/ |/2 |

|Quad tight |/ |/2 |

|Sacral base fixation |/ |/2 |

|Cervical trg pts | |/10 |

|Thoracic trg pts | |/8 |

|Lumbar trg pts | |/6 |

|Allodenia |/28 |

|R PSIS L PSIS R SI L SI |

|L 5 4 3 2 1 |

|T 12 11 10 9 8 7 6 5 4 3 2 1 |

|C 7 6 5 4 3 2 1 |

Notes:

Minors Sign + -

Total ________ Total__________

COMPLETE DIAGNOSIS

Diagnosis’ designated by a number

|Cervical |Lumbar |Shoulder |

| | | |

|____739.1 Cervical Subluxation |____739.3 Lumbar subluxation |____726.10 Bursitis |

|____723.1 Cervicalgia (I) |____724.2 Lumbago (I) |____719.41 Pain in shoulder joint |

|____722.4 Cervical Disc Degeneration (III) |____722.52 Lumbar Degeneration (III) |____726.90 Shoulder Tendonitis |

|____847.0 Cervical Sprain/Strain (II) |____724.8 Facet Syndrome (II) |____840.0 AC joint sprain |

|____723.4 Brachial neuritis/radiculitis (II) |____724.4 Lumbar Neuritis (II) | |

|____723.5 Torticollis (II) |____756.12 Spondylolisthesis (II) |Wrist/Hand/Fingers |

|____721.0 Cervical Spondylosis w/o myelopathy (I) |____721.3 Spondylosis w/o myelopathy (I) | |

|____722.71 IVD disorder w/ myelopathy |____722.10 Displacement disc w/o myelopathy (III) |____729.5 Pain in Hands |

|____723.0 Spinal Stenosis Cervical (II) |____722.73 IVD disorder w/ myelopathy | |

|____723.3 Cervicobracial Syndrome (II) |____722.83 Post laminectomy syndrome (III) |Knee |

|____722.0 Displacement.disc w/o myelopathy (III) |____724.3 Sciatica (III) | |

|____722.81 Post laminectomy syndrome (III) |____729.1 Myofascitis (II) |____719.46 Knee Pain in Joint |

|____729.1 Myofascitis (II) |____728.85 Muscle Spasm | |

|____728.85 Muscle spasm | |Ankle |

| | | |

| | |____719.47 Ankle Pain in Joint |

|Thoracic |Sacrum |Hip |

| | | |

|____739.2 Thoracic Subluxation |____739.4 Sacral Subluxation |____719.45 Hip Pain in Joint |

|____724.1 Thoracic Pain (I) |____846.1 Sprain/Strain Sacroilliac (II) | |

|____722.51 Thoracic Disc Degeneration (III) |____724.6 Disorders of the sacrum (II) |Misc Diagnosis |

|____847.1 Thoracic Sprain/Strain (II) |____729.1 Myofascitis (II) | |

|____724.4 Thoracic Neuritis/Radiculitis (II) |____728.85 Muscle Spasm |____784.0 Cephalgia (I) |

|____353.0 Brachial Plexus lesion(Thoracic outlet) (II)|____720.0 Ankylosing Spondylitis |____307.81 Tension Headache (I) |

|____724.01 Thoracic spinal stenosis (II) |____720.2 Sacralitis |____754.2 Congenital Scoliosis |

|____722.82 Post laminectomy syndrome (III) | |____386.0 Vertigo |

|____721.2 Thoracic spondylosis w/o myelopathy (I) |Pelvis |____351.00 Bells Palsy |

|____722.72 IVD disorder w/ myelopathy | |____780.4 Dizziness |

|____729.1 Myofascitis (II) |____739.5 Illium Subluxation |____756.15 Fusion of Spine-congenital |

|____728.85 Muscle Spasm | |____737.43 Scoliosis – acquired |

EXPLANATION OF EXAM FORM

Cervical Ranges of Motion

Exam = Exam findings for range of motion

P = pain; a check in this box means there was pain during this range of motion

Cervical Tests

Foraminal Compression = when marked (+) this tests for foraminal encroachment

Maximal Foraminal Compression = when marked (+) this tests for nerve root or facet involvement

Shoulder Depressor = when marked (+) this tests for adhesion of the cervical nerve roots, dural sleeves, or joint capsules

Soto Hall = when marked (+) this tests for subluxation, disc herniation, fracture, sprain/strain, posterior ligament damage

Valsalva’s Test = when marked (+) this tests for space occupying lesions like disc bulge or disc herniation

Thoracolumbar Ranges of Motion

Exam = Exam findings for range of motion

P = pain; a check in this box means there was pain during this range of motion

Lumbar Tests

Minor’s Sign = when marked (+) this tests for Lumbosacral pathology

Kemps = when marked (+) this tests for biomechanical joint dysfunction such as facet syndrome, subluxation

Bechterew’s Test = when marked (+) this tests for lumbar nerve irritation

SLR = when marked (+) this tests for lumbosacral pathology including, biomechanical joint dysfunction, disc herniation

Valsalva’s Test = when marked (+) this tests for space occupying lesions like disc bulge or disc herniation

Nachlas = when marked (+) this tests for lumbosacral biomechanical joint dysfunction

Elys = when marked (+) this tests lumbosacral or sacroiliac biomechanical joint dysfunction

Palpatory Findings

L = level (cervical 1-7, thoracic 1-12, lumbar 1-5)

Left side of body is noted to the left of the (L)

Right side of the body is noted to the right of the (L)

P = Pain; when marked there was pain over corresponding level

E = Edema; when marked there was edema over corresponding level

S = Spasm; when marked there was spasm over corresponding level

F = Fixation; when marked there was articular fixation found at the corresponding level

1 = mild 2 = moderate 3 = severe

K = knee A = ankle S = shoulder W = wrist

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