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SUBJECTIVE
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HISTORY
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Patient History
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Chief Complaint
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Mechanism of Injury
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Frequency/Quality
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Radiation of Symptoms
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Change in complaint/VAS
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Modifying factors
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Previous Episodes
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Previous Care
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Recent Diagnostic Test
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ADL/Functional Deficits
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Patient Subjective Goal
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SYSTEMS REVIEW
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Musculoskeletal
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Neurological
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Head & ENT
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Cardiovascular
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Respiratory
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Gastrointestinal
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Genitourinary
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Endocrine
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Dermatology/Hemo
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Allergy/Senstivity
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Past, Family and Social History
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Past Medical Hx
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Family Hx
• • •
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Employment Status
• • •
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Exercise Habits
• • •
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Social Habits
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OBJECTIVE
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General
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Vital Signs: Height/Weight
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Blood Pressure
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HEENT
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Neck
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Skin
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Heart
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Chest
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Abdomen
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Back
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Extremities
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Neuro
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Musculoskeletal
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ROM
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Cervical
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Cervical extension (AROM normal 45°) - current
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Cervical flexion (AROM normal 45°) - current
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Cervical left lateral flexion (AROM normal 45°) - current
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Cervical right lateral flexion (AROM normal 45°) - current
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Cervical left rotation (AROM normal 80°) - current
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Cervical right rotation (AROM normal 80°) - current
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Shoulder
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L Shoulder extension (AROM normal 60°)
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R Shoulder extension (AROM normal 60°)
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L Shoulder flexion (AROM normal 180°)
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R Shoulder flexion (AROM normal 180°)
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L Shoulder abduction (AROM normal 180°)
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R Shoulder abduction (AROM normal 180°)
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L External rotation (AROM normal 90°)
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R External rotation (AROM normal 90°)
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L Internal rotation (AROM normal 70°)
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R Internal rotation (AROM normal 70°)
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Elbow & Forearm
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L Elbow extension (AROM normal 0°) - current
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R Elbow extension (AROM normal 0°) - current
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L Elbow flexion (AROM normal 135°) - current
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R Elbow flexion (AROM normal 135°) - current
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L Forearm pronation (AROM normal 90°) - current
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R Forearm pronation (AROM normal 90°) - current
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L Forearm supination (PROM normal 90°) - current
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R Forearm supination (AROM normal 90°) - current
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Lumbar
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Lumbarsacral extension (AROM normal 30°) - current
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Lumbarsacral flexion (AROM normal 80°) - current
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Lumbarsacral left lateral flexion (AROM normal 35°) - current
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Lumbarsacral right lateral flexion (AROM normal 35°) - current
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Lumbarsacral left rotation (AROM normal 45°) - current
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Lumbarsacral right rotation (AROM normal 45°) - current
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Hip
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L Hip extension (AROM normal 30°)
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R Hip extension (AROM normal 30°)
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L Hip flexion (AROM normal 120°)
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R Hip flexion (AROM normal 120°)
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L Hip abduction (AROM normal 45°)
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R Hip abduction (AROM normal 45°)
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L Hip adduction (AROM normal 30°)
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R Hip adduction (AROM normal 30°)
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Knee
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L Knee extension (AROM normal 0°)
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R Knee extension (AROM normal 0°)
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L Knee flexion (AROM normal 135°)
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R Knee flexion (AROM normal 135°)
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Muscle Testing
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Cervical Flexors
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Cervical Extensors
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L Shoulder Flexors
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R Shoulder Flexors
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L Shoulder Extension
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R Shoulder Extension
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L elbow extension
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R elbow extension
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L elbow flexion
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R elbow flexion
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Cervical Flexors
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Cervical Flexors
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