Regional Examination Patient:______date: ______ Check normal, circle & describe abnormal (dd/mm/yr) CC & signifi cant history: ______Insurance: ______Date of birth: ______M/F Fracture screen (tuning fork, , torsion test, grip strength): □ WWNLNL, □ RReferefer fforor XX-ra-ray: ______

Observation: □ WWNLNL Palpation: □ WWNL,NL, texture, tenderness, pain referral Development: □ ggood,ood, □ ffair,air, □ ppooroor RRightight LLefteft □ Antalgia:Antalgia: ______Palpation L R Palpation L R □ SSkinkin (bruising,(bruising, sscars):cars): ______Medial epicondyle Common exten. □ Asymmetry:Asymmetry: ______Ulnar groove Anconeus Observation □ WNL L R Med. collateral ligament Common fl exor tendon Extensor carpi ulnaris Head tilt Flexor carpi ulnaris Extensor carpi rad longus Head rotation Palmaris longus Extensor carpi rad brevis high Flexor carpi radialis Extensor digitorum Shoulder rounded Pronator teres Supinator rotated tendon tendon Elbow fl exed Head of radius Triceps muscle Elbow hyperextended Radial tunnel Olecranon Valgus Lateral epicondyle Olecranon bursa Varus forearm Lat. collateral ligament Cubital fossa Forearm pronated Lat. supracondylar ridge Brachialis Forearm supinated ______Hand/fi nger deformity ______Neurologic: □ WWNLNL Orthopedic: □ WWNLNL Refl exes (0-5), □ WNL L R Instability L R Lateral epicondylitis LR Vascular Screen: □ WWNLNL Biceps (C5) Valgus stress (0°) Book lift test (0-4) L R Brachioradialis (C6) Valgus stress (30°) Cozen’s Brachial Triceps (C7) Varus stress (0°) Mill’s Radial pulse General grip strength Varus stress (30°) Kaplan’s test Ulnar pulse Motor (0-5), □ WNL L R Blanch test Medial epicondylitis LR Neuropathy L R Shoulder fl exors Allen’s test Reverse Cozen’s Tinel’s (elbow) Shoulder extensors Temperature Reverse Mill’s Tinel’s (wrist) Biceps brachii (musc.) Reverse book lift Elbow fl exion test Brachialis (musc.) Pronator stretch test ROM & Play: □ WWNLNL Brachioradialis (radial) □ PPainain atat endend ROM:ROM: ______Triceps brachii (radial) Dynamometer L R L R L R □ AAbnormalbnormal mmotion:otion: ______Wrist extensors (radial) Repeat 3 times Wrist fl exors (median/ulnar) Active Passive Serial #______Setting: ______ROM Wrist abductors (median/radial) ______LRLR Wrist adductors (ulnar/radial) ______Flexion (150°) Pronator teres (median) ______Extension (0°) Supinator (radial) ______Supination (90°) Finger fl exors (median/ulnar) ______Pronation (90°) Finger extensors (radial) NNeckeck eevaluation:valuation: ______SShoulderhoulder eeval:val: ______Joint Play L R Girth*, □ WNL L R WWrist/handrist/ eeval:val: ______Ulnohumeral Mid Radiohumeral Elbow DDx: ______Proximal radioulnar Mid forearm ______Carrying angle ______**Atrophy,Atrophy, swelling,swelling, dominantdominant vs.vs. non-dominantnon-dominant ______***General*General seensationnsation isis donedone throughthrough palpationpalpation

This form is a comprehensive checklist of examination procedures. Each item should be utilized as a diagnostic option based on the patient’s presenting symptoms and the clinical discretion of the examiner. Every procedure does not have to be performed on every patient. Some procedures may be Signature: Date: contraindicated in certain situations. Patient information contained within this form is considered strictly confi dential. Reproduction is permitted for personal use, not for resale or redistribution. www.prohealthsys.com ©2005 by Professional Health Systems Inc. All rights reserved. “Dedicated to Clinical Excellence.”