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APPENDIX 4 SAMPLE FORMS /g // letsgaue Date: Date: signature: Therapist signature: Client Comments: LENGTH: LEG Comments: MUSCULATURE: Other: ___ Hammer-toes ___ foot Splay ___ ray first Plantar-flexed ___ Valgus Hallux ___ Pronation Hyper ANKLE/FOOT/TOES: Comments: MUSCULATURE: Other: ___ Angle Q Reduced KNEES: Comments: MUSCULATURE HIPS: Comments: MUSCULATURE: SPINE: Comments: MUSCULATURE: FINGERS: WRISTS: ELBOWS: EXTREMITIES: UPPER Comments: MUSCULATURE: CLAVICLES: SCAPULAE: SHOULDERS: Comments: MUSCULATURE: EARS: EYES: Details: Y/N Contra-indications: Other: ___ curve Lordotic Excessive HEAD/NECK: type: Body Comments: WHR: (cm): circumferences Body name: Client Comments: _____ (%) fat Body _____ (mm) fat Body _____ BMI _____ (kg) Weight _____ (m) Height objectives: Current Date: Even ___ Pelvic tilt ___ Coxa Vara ___ Coxa Valga ___ Other: ___ Valga Coxa ___ Vara Coxa ___ tilt Pelvic ___ Even Level ___ Other: ___ Level ______Level ___ Other: ___ Level Normal ___ Kyphosis ___ Lordosis ___ Flat back ___ Scoliosis ___ Other: ___ Scoliosis ___ back Flat ___ Lordosis ___ Kyphosis ___ Normal Even ___ Genu Valgus ___ Genu Varus ___ Genu recurvatum ___ Patella squint ___ Excess Q Angle ___ Angle Q Excess ___ squint Patella ___ recurvatum Genu ___ Varus Genu ___ Valgus Genu ___ Even Even ___ Other: ___ Even Even ___ Other: ___ Even Other: ___ Recurvatus Cubitus ___ Valgus Cubitus ___ Varus Cubitus ___ Even Ectomorph ___ Mesomorph ___ Endomorph ___ Endomorph ___ Mesomorph ___ Ectomorph Even ___ Adducted ___ Abducted ___ Winged ___ Rotated ___ Other: ___ Rotated ___ Winged ___ Abducted ___ Adducted ___ Even Level ___ Other: ___ Level Tilted left ___ Tilted right ___ Rotated left ___ Rotated right ___ Forward ___ Flat Lordotic curve ___ curve Lordotic Flat ___ Forward ___ right Rotated ___ left Rotated ___ right Tilted ___ left Tilted Level ___ Right high ___ Left high ___ Rounded ___ Other: ___ Rounded ___ high Left ___ high Right ___ Level Even ___ Discrepancy ___ True ___ Apparent ___ Apparent ___ True ___ Discrepancy ___ Even : Even ___ Other: ___ Even : Even ___ Other: ___ Even Other: ___ Even Other: ___ Even Even ___ Tibial torsion ___ Varus heels ___ Valgus heels ___ Pes Planus ___ Pes Cavus ___ Cavus Pes ___ Planus Pes ___ heels Valgus ___ heels Varus ___ torsion Tibial ___ Even Hang evenly ___ Rotated ___ Other: ___ Rotated ___ evenly Hang Chest ___ Waist ___ Hips ___ Upper Arm L ___ R ___ Upper Leg L ___ R ___ Lower Leg L ___ R ___ R ___ L Leg Lower ___ R ___ L Leg Upper ___ R ___ L Arm Upper ___ Hips ___ Waist ___ Chest POSTURAL ASSESSMENT/BODY ALIGNMENTS ASSESSMENT/BODY POSTURAL PHYSICAL ASSESSMENT FORM (PAGE 1) (PAGE FORM ASSESSMENT PHYSICAL Comments: 411 APPENDIX 4 SAMPLE FORMS _ PHYSICAL PHYSICAL ASSESSMENT FORM (PAGE 2) RANGE RANGE OF MOVEMENT ASSESSMENTS (DEGREES OR CM) Flexion ____ Hyperextension ____ Left Rotation ____ Left Flexion ____ Right Flexion ____ Left Extension ____ Left Flexion ____ Right Flexion ____ Left Hyperextension ____ Flexion ____ Hyperextension ____ Left Rotation ____ Right Rotation ____ Left Dorsiflexion ____ Right Dorsiflexion ____ Left Plantarflexion ____ Left Flexion ____ Right Flexion ____ Left Hyperextension ___ Left Flexion ____ Right Flexion ____ Left Hyperextension ____ Client signature:Therapist signature: Date: Date: KNEE: ANKLE: Right Plantarflexion ____ Left Inversion ____ Right Inversion ____ LeftRight Eversion ____ Eversion ____ Comments: HIP: Right Rotation ____ Left Lateral Flexion ____ Right Lateral Flexion ____ Comments: Right Hyperextension ____ Left Abduction ____ Right Abduction ____ Left Medial Rotation ____ Right Medial Rotation ____ Left Lateral Rotation ____ Right Lateral Rotation ____ Left Horizontal Abduction ____ Right Horizontal Abduction ____ Left Horizontal Adduction ____ Right Horizontal Adduction ____ Comments: ELBOW/FOREARM: Right Hyperextension ____ Left Abduction ____ Right Abduction ____ Left Adduction ____ Right Adduction ____ Left Medial Rotation ____ Right Medial Rotation ____ Left Lateral Rotation ____ Right Lateral Rotation ____ Comments: THORACIC/LUMBAR: THORACIC/LUMBAR: SHOULDER: Right Extension ____ Left Pronation ____ Right Pronation ____ Left Supination ____ Right Supination ____ Comments: CERVICAL: CERVICAL: Left Lateral Flexion ____ Right Lateral Flexion ____ Comments: Right Hyperextension ____ Comments: // g 412

APPENDIX 4 SAMPLE FORMS /g // letsgaue Date: Date: signature: Therapist signature: Client Comments: Other: ____ cadence Normal ____ gait Steady PATTERN: GAIT GENERAL Comments: Other: ___ dorsiflexion Excess ANKLES/FEET: Comments: KNEES: Comments: LEGS: Comments: HIPS: Comments: ARMS: Comments: SHOULDERS: Comments: TRUNK: Comments: HEAD: Free and even movement during stance and swing ___ Other: ___ swing and stance during movement even and Free Free and even movement during stance and swing ___ Other: ___ swing and stance during movement even and Free Upright ___ Forward flexed ___ Deviated laterally ___ Other: ___ laterally Deviated ___ flexed Forward ___ Upright Reciprocal swing ___ Even motion ___ Other: ___ motion Even ___ swing Reciprocal Free and even movement during stance and swing ___ Other: ___ swing and stance during movement even and Free Upright ___ Forward flexed ___ Deviated laterally ___ Other: ___ laterally Deviated ___ flexed Forward ___ Upright Free and even movement during stance and swing ___ Other: ___ swing and stance during movement even and Free Heel strike ___ Propulsion ___ Excess pronation ___ Excess supination ___ Foot slap ___ slap Foot ___ supination Excess ___ pronation Excess ___ Propulsion ___ strike Heel Step length even ____ Normal Stride width ____ Normal Foot Angle ____ Pain-free gait ____ gait Pain-free ____ Angle Foot Normal ____ width Stride Normal ____ even length Step ANALYSIS OF MOVEMENT PARAMETERS MOVEMENT OF ANALYSIS PHYSICAL ASSESSMENT FORM (PAGE 3) (PAGE FORM ASSESSMENT PHYSICAL REVIEWED OBJECTIVES REVIEWED RECOMMENDATIONS GAIT ASSESSMENT GAIT