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General WNL
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General Abnormal
• • •
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General Comments
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A O x3
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|
HEENT WNL
|
HEENT Abnormal
• • •
|
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Skin WNL
|
Skin Lesion
|
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Neck WNL
|
Neck Abnormal
• • •
|
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Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
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Lungs WNL
|
Lungs Abnormal
• • •
|
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Abdomen WNL
|
Abdomen Abnormal
• • •
|
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MSK WNL
|
MSK Abnormal
• • •
|
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Abnormal system findings comments
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|
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Neuro WNL
|
Neuro Abnormal
• • •
|
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Extremities WNL
|
Extrem Abnormal
• • •
|
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Cervical Exam
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|
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Appearance
• • •
|
appearance comments
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ROM limited in
|
|
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Compression Test
|
|
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Left Facet Tenderness
• • •
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Right Facet Tenderness
• • •
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Spurling's
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Midline Tenderness
• • •
|
|
Left Suprascapular nerve tenderness
|
Right Suprascapular nerve tenderness
|
|
Left Occipital nerve tenderness
|
Right Occipital nerve tenderness
|
|
Thoracic Exam
|
|
|
Appearance
• • •
|
appearance comments
|
|
Midline Tenderness
• • •
|
|
|
ROM limited in
|
ROM Comments
|
|
Facet Tenderness, Left
• • •
|
Facet Tenderness, Right
• • •
|
|
Lumbar Exam
|
|
|
Appearance
• • •
|
appearance comments
|
|
Midline Tenderness
• • •
|
Paralumbar Tenderness
• • •
|
|
Facet Tenderness, Right
• • •
|
Facet Tenderness, Left
• • •
|
|
PSIS
|
|
|
Flexion
|
Extension
|
|
Right Lateral Flexion
|
Left Lateral Flexion
|
|
ROM Comments
|
Gait
|
|
Rt. Straight Leg Raise
|
Rt. SLR Degrees
|
|
Lt. Straight Leg Raise
|
Lt. SLR Degrees
|
|
Sacroiliac joint testing
|
|
|
Patrick/FABERE
|
Compression Test
|
|
Gaenselens
|
Sacral Thrust
|
|
Knee Examination
|
|
|
Knee Joint Examination
|
|
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Effusion [-]
|
Effusion [+]
|
|
Effusion (R)
|
Effusion (R) -- Severity
|
|
Effusion (L)
|
Effusion (L) -- Severity
|
|
Tenderness [-]
|
Tenderness [+]
|
|
Tenderness (R)
|
Tenderness (R) -- Severity
|
|
Tenderness (L)
|
Tenderness (L) -- Severity
|
|
Weakness
|
|
|
Valgus Instability [-]
|
Valgus Instability [+]
|
|
Valgus Instability (R)
|
Valgus Instability (R) -- Severity
|
|
Valgus Instability (L)
|
Valgus Instability (L) -- Severity
|
|
Varus Instability [-]
|
Varus Instability [+]
|
|
Varus Instability (R)
|
Varus Instability (R) -- Severity
|
|
Varus Instability (L)
|
Varus Instability (L) -- Severity
|
|
Patellar Instability [-]
|
Patellar Instability [+]
|
|
Patellar Instability (R)
|
Patellar Instability (R) -- Severity
|
|
|
Patellar Instability (R) -- Direction
• • •
|
|
Patellar Instability (L)
|
Patellar Instability (L) -- Severity
|
|
Patellar Instability (L) -- Direction
• • •
|
ROM Flexion (N = 180)
• • •
|
|
Quadriceps Strength
• • •
|
Hamstrings Strength
• • •
|
|
Lachman's Test [-]
|
Lachman's Test [+]
|
|
Lachman's Test (R) -- Positive
|
Lachman's Test (L) -- Positive
|
|
Lachman's Test (L) -- End Point
|
|
|
McMurray Test
• • •
|
|
|
Patellar Tracking [-]
|
Patellar Tracking [+]
|
|
Patellar Tracking (R) -- Abnormal Motion
|
Patellar Tracking (R) -- Direction of Abnormal Motion
• • •
|
|
Patellar Tracking (L) -- Abnormal Motion
|
Patellar Tracking (L) -- Direction of Abnormal Motion
• • •
|
|
Patellar Tracking (R) -- Abnormal Motion
|
Patellar Tracking (R) -- Direction of Abnormal Motion
• • •
|
|
Patellar Tracking (L) -- Abnormal Motion
|
Patellar Tracking (L) -- Direction of Abnormal Motion
• • •
|
|
Gait
• • •
|
|
|
Hip Examination
|
|
|
Hip Joint Examination
|
|
|
Pain [-]
|
Pain [+]
|
|
Pain (R)
|
Pain (R) -- Movement
• • •
|
|
Pain (L)
|
Pain (L) -- Movement
• • •
|
|
Tenderness [-]
|
Tenderness [+]
|
|
Tenderness (R)
|
Tenderness (R) -- Location
• • •
|
|
Tenderness (L)
|
Tenderness (L) -- Location
• • •
|
|
ROM Hips
• • •
|
Hip Strength
• • •
|
|
Gait
• • •
|
Leg Lengths
|
|
Are leg lengths equal?
|
Leg Lengths Unequal -- Description
|
|
Shoulder Examination
|
|
|
Shoulder Joint Examination
|
|
|
Pain [-]
|
Pain [+]
|
|
Pain (R)
|
Pain (R) -- Movement
• • •
|
|
Pain (L)
|
Pain (L) -- Movement
• • •
|
|
Tenderness [-]
|
Tenderness [+]
|
|
Tenderness (R)
|
Tenderness (R) -- Location
• • •
|
|
Tenderness (L)
|
Tenderness (L) -- Location
• • •
|
|
Deformity [-]
|
Deformity [+]
|
|
Deformity (R)
|
Deformity (R) -- Location
• • •
|
|
Deformity (L)
|
Deformity (L) -- Location
• • •
|
|
Instability [-]
|
Instability [+]
|
|
Instability (R)
|
Instability (R) -- Location
• • •
|
|
Instability (L)
|
Instability (L) -- Location
• • •
|
|
Swelling [-]
|
Swelling [+]
|
|
Swelling (R)
|
Swelling (R) -- Location
• • •
|
|
Swelling (L)
|
Swelling (L) -- Location
• • •
|
|
Rotator Cuff Strength
• • •
|
Biceps Strength
• • •
|
|
Triceps Strength
• • •
|
Deltoid Strength
• • •
|
|
ROM Flexion
• • •
|
ROM Extension
• • •
|
|
ROM Abduction
• • •
|
ROM External Rotation
• • •
|
|
ROM Internal Rotation
• • •
|
Drop Arm Test
• • •
|
|
Impingement Test
• • •
|
|
