PHYSICAL EXAMINATION FORM Patient Name ______

PHYSICAL EXAMINATION FORM Patient Name ______Date______Date______

Exam Findings Points Notes: Exam Findings Points FRI ------/40 FRI ------/40 Limp /1 Limp /1 Guarded M/Mod/S /3 Guarded M/Mod/S /3 Antalgic P /2 Minors Sign + - Antalgic P /2 Ant. Head /1 Ant. Head /1 Ant. Shoulder Roll R L B /2 Ant. Shoulder Roll R L B /2 Head tilt /1 Head tilt /1 Head Rot /1 Head Rot /1 Elevated shoulder /1 Elevated shoulder /1 Scapular retraction /1 Scapular retraction /1 Elevated hip /1 Elevated hip /1 External Foot Flare R L B /2 External Foot Flare R L B /2 Lumbar Flex /60 P /2 Lumbar Flex /60 P /2 Lumbar Ext /25 P /2 Lumbar Ext /25 P /2 Lumbar L Lat /25 P /2 Lumbar L Lat /25 P /2 Lumbar R Lat /25 P /2 Lumbar R Lat /25 P /2 Kemps / /2 Kemps / /2 Bicepts Reflex / /2 Bicepts Reflex / /2 Patellar Reflex / /2 Patellar Reflex / /2 Bechterew Test / /2 Bechterew Test / /2 Hamstring Tight / /2 Hamstring Tight / /2 Cervical Flex /50 P /2 Cervical Flex /50 P /2 Cervical Ext /60 P /2 Cervical Ext /60 P /2 Cervical L Lateral /45 P /2 Cervical L Lateral /45 P /2 Cervical R Lateral /45P /2 Cervical R Lateral /45P /2 Cervical L Rot /80 P /2 Cervical L Rot /80 P /2 Cervical R Rot /80 P /2 Cervical R Rot /80 P /2 Maximal Compress / /2 Maximal Compress / /2 Shoulder Depress / /2 Shoulder Depress / /2 Soto Hall / /1 Soto Hall / /1 Valsalva / /1 Valsalva / /1 DeJerines / /1 DeJerines / /1 SLR / /2 SLR / /2 Ely’s / /2 Ely’s / /2 Nachlas / /2 Nachlas / /2 Quad tight / /2 Quad tight / /2 Sacral base fixation / /2 Sacral base fixation / /2 Cervical trg pts /10 Cervical trg pts /10 Thoracic trg pts /8 Thoracic trg pts /8 Lumbar trg pts /6 Lumbar trg pts /6 Allodenia /28 Allodenia /28 R PSIS L PSIS R SI L SI R PSIS L PSIS R SI L SI L 5 4 3 2 1 L 5 4 3 2 1 T 12 11 10 9 8 7 6 5 4 3 2 1 T 12 11 10 9 8 7 6 5 4 3 2 1 C 7 6 5 4 3 2 1 C 7 6 5 4 3 2 1 Total ______Total______COMPLETE DIAGNOSIS Diagnosis’ designated by a number Cervical Lumbar Shoulder

____739.1 Cervical Subluxation ____739.3 Lumbar subluxation ____726.10 Bursitis ____723.1 Cervicalgia (I) ____724.2 Lumbago (I) ____719.41 Pain in shoulder joint ____722.4 Cervical Disc Degeneration (III) ____722.52 Lumbar Degeneration (III) ____726.90 Shoulder Tendonitis ____847.0 Cervical Sprain/Strain (II) ____724.8 Facet Syndrome (II) ____840.0 AC joint sprain ____723.4 Brachial neuritis/radiculitis (II) ____724.4 Lumbar Neuritis (II) ____723.5 Torticollis (II) ____756.12 Spondylolisthesis (II) Wrist/Hand/Fingers ____721.0 Cervical Spondylosis w/o myelopathy (I) ____721.3 Spondylosis w/o myelopathy (I) ____722.71 IVD disorder w/ myelopathy ____722.10 Displacement disc w/o myelopathy (III) ____729.5 Pain in Hands ____723.0 Spinal Stenosis Cervical (II) ____722.73 IVD disorder w/ myelopathy ____723.3 Cervicobracial Syndrome (II) ____722.83 Post laminectomy syndrome (III) Knee ____722.0 Displacement.disc w/o myelopathy (III) ____724.3 Sciatica (III) ____722.81 Post laminectomy syndrome (III) ____729.1 Myofascitis (II) ____719.46 Knee Pain in Joint ____729.1 Myofascitis (II) ____728.85 Muscle Spasm ____728.85 Muscle spasm Ankle

____719.47 Ankle Pain in Joint Thoracic Sacrum Hip

____739.2 Thoracic Subluxation ____739.4 Sacral Subluxation ____719.45 Hip Pain in Joint ____724.1 Thoracic Pain (I) ____846.1 Sprain/Strain Sacroilliac (II) ____722.51 Thoracic Disc Degeneration (III) ____724.6 Disorders of the sacrum (II) Misc Diagnosis ____847.1 Thoracic Sprain/Strain (II) ____729.1 Myofascitis (II) ____724.4 Thoracic Neuritis/Radiculitis (II) ____728.85 Muscle Spasm ____784.0 Cephalgia (I) ____353.0 Brachial Plexus lesion(Thoracic outlet) (II) ____720.0 Ankylosing Spondylitis ____307.81 Tension Headache (I) ____724.01 Thoracic spinal stenosis (II) ____720.2 Sacralitis ____754.2 Congenital Scoliosis ____722.82 Post laminectomy syndrome (III) ____386.0 Vertigo ____721.2 Thoracic spondylosis w/o myelopathy (I) Pelvis ____351.00 Bells Palsy ____722.72 IVD disorder w/ myelopathy ____780.4 Dizziness ____729.1 Myofascitis (II) ____739.5 Illium Subluxation ____756.15 Fusion of Spine-congenital ____728.85 Muscle Spasm ____737.43 Scoliosis – acquired

EXPLANATION OF EXAM FORM

Cervical Ranges of Motion Exam = Exam findings for range of motion P = pain; a check in this box means there was pain during this range of motion Cervical Tests Foraminal Compression = when marked (+) this tests for foraminal encroachment Maximal Foraminal Compression = when marked (+) this tests for nerve root or facet involvement Shoulder Depressor = when marked (+) this tests for adhesion of the cervical nerve roots, dural sleeves, or joint capsules Soto Hall = when marked (+) this tests for subluxation, disc herniation, fracture, sprain/strain, posterior ligament damage Valsalva’s Test = when marked (+) this tests for space occupying lesions like disc bulge or disc herniation Thoracolumbar Ranges of Motion Exam = Exam findings for range of motion P = pain; a check in this box means there was pain during this range of motion Lumbar Tests Minor’s Sign = when marked (+) this tests for Lumbosacral pathology Kemps = when marked (+) this tests for biomechanical joint dysfunction such as facet syndrome, subluxation Bechterew’s Test = when marked (+) this tests for lumbar nerve irritation SLR = when marked (+) this tests for lumbosacral pathology including, biomechanical joint dysfunction, disc herniation Valsalva’s Test = when marked (+) this tests for space occupying lesions like disc bulge or disc herniation Nachlas = when marked (+) this tests for lumbosacral biomechanical joint dysfunction Elys = when marked (+) this tests lumbosacral or sacroiliac biomechanical joint dysfunction Palpatory Findings L = level (cervical 1-7, thoracic 1-12, lumbar 1-5) Left side of body is noted to the left of the (L) Right side of the body is noted to the right of the (L) P = Pain; when marked there was pain over corresponding level E = Edema; when marked there was edema over corresponding level S = Spasm; when marked there was spasm over corresponding level F = Fixation; when marked there was articular fixation found at the corresponding level 1 = mild 2 = moderate 3 = severe K = knee A = ankle S = shoulder W = wrist