| Normal UE Exam | Normal LE Exam | 
| GAIT | Gait Free Text | 
| 1st Site Examined |  | 
| Inspection/Palpation• • • | Inspection/Palpation Free Text | 
| Muscle Strength | Muscle Strength Free Text | 
| Instability• • • | Instability Free Text | 
| Active ROM• • • | Active ROM Free Text | 
| Passive ROM• • • | Passive ROM Free Text | 
| Skin• • • | Skin Free Text | 
| Upper Extremity Special Tests• • • |  | 
| Lower Extremity Special Tests• • • | Special Test Free Text | 
| EXAM Free Text |  | 
| 2nd Site Examined |  | 
| Inspection/Palpation• • • | Inspect/Palpation Free Text | 
| Muscle Strength | Muscle Strength Free Text | 
| Instability• • • | Instability Free Text | 
| Active ROM• • • | Active ROM | 
| Passive ROM• • • | Passive ROM Free Text | 
| Skin• • • | Skin Free Text | 
| Upper Extremity Special Test• • • |  | 
| Lower Extremity Special Test• • • | Special Tests Free Text | 
| EXAM FREE TEXT |  | 
| 3rd Site Examined |  | 
| Inspection/Palpation• • • | Inspection/Palpation Free Text | 
| Muscle Strength |  | 
| Instability• • • | Instability Free Text | 
| Active ROM• • • | Active ROM Free Text | 
| Passive ROM• • • | Passive ROM Free Text | 
| Skin• • • | Skin Free Text | 
| Upper Extremity Special Tests• • • |  | 
| Lower Extremity Special Tests• • • | Special Test Free Text | 
| Exam Free Text |  | 
|  |  | 
| LEFT XRAY HERE• • • | LEFT OUTSIDE XRAY• • • | 
| LEFT XRAY DROPBOX• • • | LEFT XRAY FREE TEXT | 
| RIGHT XRAY HERE• • • | RIGHT OUTSIDE XRAY• • • | 
| RIGHT XRAY DROPBOX• • • | RIGHT XRAY FREE TEXT | 
| MRI• • • | CT SCAN• • • | 
| EMG• • • | BONE SCAN/DEXA• • • | 
| MRI FINDINGS | MRI/CT/EMG/BS/DEXA Results | 

