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Cervical Rotation (R) / 85 degre
With Pain?
Cervical Rotation (L) / 85 degre
With Pain?
Cervical Lat Flexion (R) / 45 de
With Pain?
Cervical Lat Flexion (L) / 45 de
WIth Pain?
Cervical Flexion / 65 degrees
With Pain?
Cervical Extension / 50 degrees
With Pain?
Lumbar Rotation (R) / 85 degrees
With Pain?
Lumbar Rotation (L) / 85 degrees
With Pain?
Lumbar Lateral Flex (R) / 35 deg
With Pain?
Lumbar Lateral Flex (L) / 35 deg
With Pain?
Lumbar Flexion / 95 degrees
With Pain?
Lumbar Extension / 35 degrees
With Pain?
Bilateral Scales: Left / Right i
/
Swelling & Inflammation
• • •
Tight Muscles
• • •
Restriction & Loss of Motion in
• • •
Palpation Notes: Cervical
Palpation Notes: Thoracic
Palpation Notes: Lumbar
Palpation Notes: Sacrum/ Pelvis
Palpation Notes: Other
Upper Ext MM Test WNL?
Upper Ext MM Comments:
Lower Ext. MM Test WNL?
Lower Ext. MM Comments:
Upper Ext. DTR WNL?
Upper Ext. DTR Comments:
Lower Ext. DTR WNL?
Lower Ext DTR Comments:

Exam Form Medical Form

Chiropractor

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Published: Feb. 10, 2012, 1:28 p.m.
Doctor: Dr. History Physical
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