|
Work: Mechanical stresses
|
Leisure: Mechanical Stresses
|
|
Disability from present episode
|
Functional Disability score
|
|
VAS Score
|
|
|
|
|
|
HISTORY
|
|
|
Present Symptoms
|
Present since
|
|
Commenced as a result of
|
Or no apparent reason
|
|
Progression
|
Comment
|
|
Symptoms at onset
• • •
|
Comment
|
|
Constant symptoms
• • •
|
Comment
|
|
Intermittent symptoms
• • •
|
|
|
Worse
|
|
|
Bending
|
Sitting
|
|
Turning
|
Lying
|
|
Rising
|
Time of the Day
• • •
|
|
Other
|
|
|
Better
|
|
|
Bending
|
Sitting
|
|
Turning
|
Lying
|
|
Time of the Day
• • •
|
Other
|
|
Sleep
|
|
|
Disturbed Sleep
|
Sleeping postures
• • •
|
|
Number of Pillows
|
Surface
|
|
Additional Sleep Info
|
|
|
|
|
|
Previous History
|
|
|
Previous Episodes
|
Year of first episode
|
|
|
Previous Treatments
|
|
SPECIFIC QUESTIONS
|
|
|
Symptoms
• • •
|
Gait / Upper Limbs
|
|
Medications
• • •
|
Other Medications
|
|
General Health
|
|
|
Imaging:
|
Type Of Imaging
|
|
Recent or major surgery
|
Type of Surgery
|
|
Unexplained weight loss
|
Changes in Weight
|
|
Accidents
|
Type of Accident
|
|
Night Pain
|
Description of Night Pain
|
|
Others
|
|
|
POSTURE
|
|
|
Sitting:
|
Comment
|
|
Standing:
|
Comment
|
|
Protruded Head:
|
Comment
|
|
Wry Neck:
|
Relevant:
|
|
Correction of Posture:
|
Other Observations:
|
|
NEUROLOGICAL
|
|
|
Motor Deficit
|
Reflexes
|
|
Sensory Deficit
|
Dural Signs
|
|
MOVEMENT LOSS
|
|
|
Protrusion
|
Pain
|
|
Flexion
|
Pain
|
|
Retraction
|
Pain
|
|
Extension
|
Pain
|
|
Lateral flexion R
|
Pain
|
|
Lateral flexion L
|
Pain
|
|
Rotation R
|
Pain
|
|
Rotation L
|
Pain
|
|
TEST MOVEMENTS
|
|
|
Pretest Symptoms sitting
|
|
|
PRO : During
• • •
|
After:
• • •
|
|
Mechanical Response
|
|
|
Rep PRO: During
• • •
|
After:
• • •
|
|
Mechanical Response
|
|
|
RET: During
• • •
|
After
• • •
|
|
Mechanical Response
|
|
|
Rep RET: During
• • •
|
After
• • •
|
|
Mechanical Response
|
|
|
RET EXT: During
• • •
|
After
• • •
|
|
Mechanical Response
|
|
|
Rep RET EXT: During
• • •
|
After
• • •
|
|
Mechanical Response
|
|
|
Addition Test Movement Info
|
|
|
Pretest Symptoms Lying
|
|
|
RET: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Rep RET: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
RET EXT: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Rep RET EXT: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Additional Test Movement Info
|
|
|
If required pretest pain sitting
|
|
|
LF - R : During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Rep LF - R: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
LF - L: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Rep LF - L: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
ROT - R: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Rep ROT - R: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
ROT - L: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Rep ROT - L: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
FLEX: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Rep FLEX: During
• • •
|
After
• • •
|
|
Mechanical Response :
|
|
|
Additional Test Movement Info
|
|
|
STATIC TESTS
|
|
|
Protrusion
• • •
|
Flexion
• • •
|
|
Retraction
• • •
|
Extension Prone
• • •
|
|
Extension Seated
• • •
|
Extension Supine
• • •
|
|
CS Orthopedic Test (positive)
• • •
|
CS Orthopedic Test (Negative)
• • •
|
|
|
|
|
PROVISIONAL CLASSIFICATION
|
|
|
If Other
|
If Derangement: Pain Location
|
|
PRINCIPLE OF MANAGEMENT
|
|
|
Education
• • •
|
|
|
Mechanical Therapy
|
Equipment Provided:
|
|
Lateral Principle:
|
Extension Principle
|
|
Other:
|
Flexion Principle
|
|
|
Treatment Goals:
|
