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Body diagram
General impression, Gait, Posture, Movement
Adhesion sites/Tenderness notes (Do not leave blank!!)
Adhesion sites/Tenderness - ThoracoLumboSacral
• • •
Adhesion sites/Tenderness - Hip/Thigh
• • •
Adhesion sites/Tenderness DETAIL notes
Adhesion sites/Tenderness - Ankle/Foot
• • •
Adhesion sites/Tenderness - Lower leg
• • •
Lumbar
Lumbar Exam notes
Lumbar ROM
Flex N:80
Ext N:40
LLF N:30
RLF N:30
LR N:40
RR N:40
Lumbar ROM notes
Lumbar Ortho
Antalgia L
Antalgia R
Listing (flex) L
Listing (flex) R
Lower cross
Lumbar ortho notes
Gillet L
Gillet R
Trendelenberg L
Trendelenberg R
Kemp's L
Kemp's R
Lumbosacral Posterior Translation L
Lumbosacral Posterior Translation R
L-P rhythm L
L-P rhythm R
Valsava
Seated flexion
Slump L
Slump R
SLR/Lasegue L
degree of SLR
SLR/Lasegue R
degree of SLR
Goldthwait L
Goldthwait R
Leg length L
Leg Length R
Modified Thomas L
Modified Thomas R
Thomas L details
• • •
Thomas R details
• • •
Toe walk L
Toe walk R
Heel walk L
Heel walk R
Lumbar ortho notes
Lumbar ortho notes
Neuro
Neuro comments
L1 S L
S R
M L
M R
L2 S L
S R
M L
M R
L3 S L
S R
M L
M R
L4 S L
S R
M L
M R
DTR L
DTR R
L5 S L
S R
M L
M R
DTR L
DTR R
S1 S L
S R
M L
M R
DTR L
DTR R
Neuro test notes
Neuro test notes
Rad: reviews?
View
Finding
Rad notes
Peripheral nerve entrapment
Nerve entrapment notes
Sciatic
Femoral, cluneal
Sciatic, post tibial, common/deep/supf peroneal
Post tibial, med plantar
Hip
Hip ROM
FL R N:150
FL L N:150
ER R N:50
ER L N:50
IR R N:40
IR L N:40
Abd R N:50
Abd L N:50
Add R N:30
Add L N:30
Ext R N:30
Ext L N:30
Hip ROM notes
Hip Ortho
FABERE R
FABERE L
FADDIR R
FADDIR L
Allis R
Allis L
Anvil R
Anvil L
Scour R
Scour L
Craig's R
Craig's L
Hip Ortho notes
Hip Ortho notes
Knee
Knee ROM
FL R N:150
FL L N:150
Ex R N:0
Ex L N:0
IR R N:5
IR L N:5
ER R N:10
ER L N:10
Knee ROM notes
Knee Ortho
Valgus R
Valgus L
Varus R
Varus L
Drawer - Ant R
Drawer - Ant L
Drawer - Post R
Drawer - Post L
Lachman R
Lachman L
Lateral Pivot Shift R
Lateral Pivot Shift L
Steinman R
Steinman L
McMurray R
McMurray L
Flex+rot R
Flex+rot L
Noble's R
Noble's L
Patella mobility R
Patella mobility L
Knee ortho notes
Knee ortho notes
Ankle and Foot
Ankle ROM
Plantarflexion R N:40
Plantarflexion L N:40
Dorsiflexion R N:25
Dorsiflexion L N:25
Pron R N:10
Pron L N:10
Supn R N:20
Supn L N:20
Ankle ROM Notes
Ankle/foot Ortho
Drawer - Ant R
Drawer - Ant L
Drawer - Post R
Drawer - Post L
Valgus R
Valgus L
Varus R
Varus L
Squeeze R
Squeeze L
1st toe ext R
1st toe ext L
Hagland R
L
Rear vl/vr R
L
Over-pronation / Dropped arch R
L
1st ray mob R
L
Ankle/foot ortho notes
Ankle/foot ortho notes
Pulse Dx
Pulse diagram
(R) Cun:
(R) Guan:
(R) Chi:
(L) Cun:
(L) Guan:
(L) Chi:
Pulse (R)
Pulse (L)
Pulse overall
Ren Ying vs Cun Kou Pulse Size
Cun Kou vs Ren Ying Pulse Size
"Zao" - Ren Ying Cun Kou Pulse
Meridian Dx from Ren Ying Cun Kou Pulse
Pulse notes

Lumbar and Lower Extremity Exam Medical Form

Chiropractor

Action Performance Care

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Published: Sept. 22, 2023, 1:41 a.m.
Doctor: Dr. History Physical
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