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Pain Diagram
Observation
Observation WNL
Antalgia
[+] Antalgia Comments
• • •
Bruising
[+] Bruising Comments
• • •
Swelling
[+] Swelling Comments
• • •
Redness
[+] Redness Comments
• • •
ABN Posture
• • •
ABN Leg Length
Step Deformity
[+] Step Deformity Comments
• • •
Scoliosis
[+] Scoliosis Comments
• • •
Trendelenburg's Sign
[+] Trendelenburg's Sign
• • •
Lumbar ROM Exam
ROM WNL
Flexion (60)
Flexion Symptoms
• • •
Extension (25)
Extension Symptoms
• • •
Left Lateral Flexion (25)
LLF Symptoms
• • •
Right Lateral Flexion (25)
RLF Symptoms
• • •
Left Rotation (10)
LR Symptoms
• • •
Right Rotation (10)
RR Symptoms
• • •
DTR
DTR WNL
Left L4
Right L4
Left S1
Right S1
Light Touch
Light Touch WNL
Left L4 Dermatome
Right L4 Dermatome
Left L5 Dermatome
Right L5 Dermatome
Left S1 Dermatome
Right S1 Dermatome
Motor Function
Motor Function WNL
Left L3 Myotome - Knee Ext
RIght L3 Myotome - Knee Ext
Left L4 Myotome - Ankle Inv
RIght L4 Myotome - Ankle Inv
Left L5 Myotome - Hallux Ext
Right L5 Myotome - Hallux Ext
Left S1 Myotome - Ankle Ev
Right S1 Myotome - Ankle Ev
ABN Heel Walk/ Toe Walk
ABN Heel/Toe Walk Comments
• • •
Othopedic Tests
Valsalva Maneuver
LEFT Kemp's Test
[+] LEFT Kemp's Comments
• • •
RIGHT Kemp's Test
[+] RIGHT Kemp's Comments
• • •
LEFT Slump Test
[+] LEFT Slump Test Comments
• • •
RIGHT Slump Test
[+] RIGHT Slump Test Comments
• • •
LEFT SLR
[+] LEFT SLR Comments
• • •
RIGHT SLR
[+] RIGHT SLR Comments
• • •
LEFT Laguerre's Test
[+] LEFT Laguerre's Test
• • •
RIGHT Laguerre's Test
[+] RIGHT Laguerre's Test
• • •
LEFT FABERE
RIGHT FABERE
Spinous Percussion
[+] Spinous Percussion
• • •
LEFT Yeoman's Test
RIGHT Yeoman's Test
LEFT Hibb's Test
RIGHT Hibb's Test
SIJ Compression
[+] SIJ Compression
• • •
LEFT Stork Test
[+] LEFT Stork Test
• • •
RIGHT Stork Test
[+] RIGHT Stork Test
• • •

Lumbopelvic Exam Medical Form

Chiropractor

Chiro Lumbopelvic Orthopedic Exam

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Published: Aug. 7, 2015, 5:13 p.m.
Doctor: Dr. History Physical
Rating: +30   /

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