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General Wellness WNL
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General Wellness Abnormal
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General Comments
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HEENT WNL
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HEENT Abnormal
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HEENT Comments
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Neck WNL
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Neck Abnormal
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Neck Comments
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MSK WNL
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MSK Abnormal
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MSK Comments
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Neuro Abnormal
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Neuro Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
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Abdomen Comments
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Upper Extremities WNL
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Upper Extremity Abnormal
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UE Comments
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Lower Extremities WNL
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Lower Extremity Abnormal
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Lower Extremity Comments:
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LE Edema
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LE Edema Comments:
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Psych WNL
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Psych Abnormal
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Skin
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Skin WNL
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Cervical Skin Abnormal
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Additional Comments:
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Lumbar Skin Abnormal
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Additional Comments:
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Spine
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Cervical Alignment
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Additional Notes
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Thoracic Spine Alignment
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Additional Notes
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Lumbar Spine Alignment
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Additional Notes
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Cervical Bony Palpation WNL
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Additional Notes
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Thoracic Bony Palpation WNL
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Additional Notes
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Lumbar Bony Palpation WNL
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Additional Notes
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Cervical Examination
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Cranial Examination
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Thoracic Examination
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Periphreal Examination
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Lumbar Examination
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Range of Motion
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Cervical ROM WNL
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Flexion _____ Degrees
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Extension_____ Degrees
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Lateral Flexion to the Right _____ Degrees
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Lateral Flexion to the Left _____ Degrees
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Rotation to the Right _____ Degrees
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Rotation to the Left _____ Degrees
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Additional Notes
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Lumbar ROM WNL
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Flexion _____ Degrees
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Extension_____ Degrees
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Additional Notes:
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Lateral Flexion to the Right _____ Degrees
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Lateral Flexion to the Left _____ Degrees
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Rotation to the left _____ degrees
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Additional Notes
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Neurological System
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Mental Orientation
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Mood/Affect
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Memory
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Speech
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Cranial Nerves II-XII
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Additional Notes
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Motor Strength
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C5 Right - Abduction Deltoid
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C5 Left - Abduction Deltoid
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C5 on the Right External Rotation Infraspinatus
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C5 on the Left External Rotation Infraspinatus
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C5 on the Right Internal Rotation Supraspinatus
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C5 on the Left Internal Rotation Suprespinatus
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C6 Right Flexion Bicep
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C6 on the Left Flexion Bicep
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C7 on the Right Extension Triceps
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C7 on the Left Extension Triceps
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C8 on the Right Abduction Fingers
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C8 on the Left Abduction Fingers
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Additional Notes:
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L1 Hip Flexion Iliopsioas on the Right
• • •
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L1 Hip Flexion Iliopsioas on the Left
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L2-4 Knee Extension Quadriceps on the Right
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L2-4 Knee extension Quadriceps on the Left
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L5 Ankle Dorsiflexion Tibialis Anterior on the Right
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L5 Ankle Dorsiflexion Tibialis Anterior on the Left
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L5 Great Toe Extension Extensor Hallucis Longus on the Right
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L5 Great Toe Extension Extensor Hallucis Longus on the Left
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S1 Plantar Flexion Gastocnemius on the Right
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S1 Plantar Flexion Gastocnemius on the Left
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Additional Notes:
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Sensations
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RUE Sensation
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LUE Sensation
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RLE Sensation
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LLE Sensation
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Additional Notes:
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Reflexes
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Triceps Reflex Right
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Triceps Reflex Left
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Biceps Reflex Right
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Biceps Reflex Left
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Brachioradialis Reflex Right
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Brachioradialis Reflex Left
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Knee Reflex Right
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Knee Reflex Left
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Ankle Reflex Right
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Ankle Reflex Left
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Additional Notes:
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Special Test
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Gait
• • •
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LUE Special Test
• • •
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RUE Special Test
• • •
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LLE Special Test
• • •
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RLE Special Test
• • •
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Proprioception/Vibration
• • •
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Pain Eliciation
• • •
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Additional Notes
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