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Swelling Normal
Swelling Right
• • •
Swelling Rt Location
• • •
Swelling Left
• • •
Swelling Lt Location
• • •
Ecchymosis Normal
Ecchymosis Right
• • •
Ecchymosis RT Location
• • •
Ecchymosis Left
• • •
Ecchymosis Lt Location
• • •
Tenderness Normal
Tenderness Right
• • •
Tenderness Rt Location
• • •
Tenderness Left
Tenderness Lt Location
• • •
ROM Dorsiflexion Normal N=20
ROM Dorsiflexion Right N=20
ROM Dorsiflexion Left N=20
Dorsiflexion Strength Normal
Dorsiflexion Strength Right
Dorsiflexion Strength Left
ROM Plantar Flexion N=40
ROM Plantar Flexion Right N=40
ROM Plantar Flexion Left N=40
Plantar Flexion Strength Normal
Plantar Flexion Strength Right
Plantar Flexion Strength Left
Heel Cord Tightness Normal
Heel Cord Tightness Right
Heel Cord Tightness Left
Equinus Contracture Normal
Equinus Contracture Right
Ankle Alignment Left
Inversion Normal
ROM Inversion Right
ROM Inversion Left N=30
ROM Eversion Normal
ROM Eversion Right
ROM Eversion Left N=20
Inversion Strength Normal
Inversion Strength Right
Inversion Strength Left
Eversion Strength Normal
Eversion Strength Right
Eversion Strength Left
Great Toe Raise Normal
Great Toe dorsi flexion Right N=
Great Toe dorsi flexion Left N=5
Great toe plantar flexion Right
Great toe plantar flexion Left N
Squeeze Test Normal
Squeeze Test Right
Squeeze Test Left
Homans Test Normal
Homans Test Right
Homans Test Left
Gait Normal
Gait Right
• • •
Gait Left
• • •
Capillary filling normal
Capillary filling Right
• • •
Capillary filling Left
• • •
Previous surgical wound
Surgical wound signs
• • •
Foot Diagram

Foot Examination Medical Form

Pain Management Specialist

Foot Examination

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Published: Feb. 8, 2013, 7:48 p.m.
Doctor: Dr. History Physical
Rating: +5   /

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Sunnyvale, CA 94089

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