Examination

1. Final Initial 10 8 6 5 4 3 7 2 In. Weight: Height: Lbs. Pulse: BPM History Yes No Yes No Yes No Birth Control Pills Hypertension Atherosclerosis History of CVA Anticoagulants Vertigo L.O.C. Coll. W/O L.O.C. Smoking Blurred Vision Tinnitis Speech or Swallowing Problems H.I.V. A.I.D.S. Left Right Left Right Auscultation for Bruits VBAI Screen Carotid Subclavian Hautant’s Test Klein’s Maneuver Cranial Nerves Left Right Left Right Left Right Left Right Left Right Left Right 1 2 3 4 5 6 7 8 9 10 11 12 BI BR TR PAT ACH C5 C6 C7 L4, L5 S1 Babinski Chaddock Gordon Hoffman Oppenheim Rhomberg Rossolimo Tromner DTR Left Right Path L R L R D.T.R. Reflexes J = Jendrassik’s 0 = Abs 1 = Hypo 2= Norm 3 = Hyper 4 = Clonus R = Reinforced Fist Left Right Left Right Deltoid Wrist Ext. Wrist Flex Finger Flex Interossei Hip Flexors Hip Add. Knee Ext. Dorsi Flex Plantar Flex Motor Strength Palpation Sensory 9 Patient Name: Date: AOCC: See DD Vital Signs Temp.: F Examination Lt.: Resp.: BPM Blood Pres.: Sit Lay Rt.: Dynamometer Grip: Lt.: Rt.: (Circle Handedness) A = Abnormal F = Facial Grimace C = No Complaint D = Edema E = Eye Wincing S = Spasm N = Normal R = Rigidity V = Verbal Upset O = Omitted 0 = Zero 1 = Trace 2= Poor 3 = Fair 4 = Good 5 = Normal Static: Motion: Musculature: AEWNL: Pinwheel: AEWNL: Vibration: AEWNL: Percussion:

2. Dejerine’s Triad Cough Sneeze Bowel Movement Orthopedic Tests Cer. Dor. Lum. Other OK Valsalva’s HA Minor’s Sign Active Verbal Car/Truck L.T.S. L L Notes Notes Hip Norm R Notes Knee Norm R Ankle Norm L R Left Right Left Right Heel Walk Toe Walk Adam’s Support. Adam’s Reversal Sign Kemp’s Sd/Sit Lasegue’s Sicard’s Leg Lowering Kernig’s Braggard’s Goldthwait’s Gaenslen’s Thomas’ Patrick’s Dbl Leg Raise Hoover’s Milgram’s Libman’s Soto-Hall’s Lindner’s SH-SB’s Jackson’s Foraminal Cp MRCCT Cervical Distr Shoulder Depr Magnuson’s Mankopff’s Burn’s Bench Ely’s Yeoman’s Spring’s Gillet’s Codman’s Dawbarn’s Dugas’ Supra PR Impingement East Costclav McMurray’s McIntosh’s Lachman’s Pat Tap Pat Scrape Mill’s T Cozen’s T Phalen’s Tinel’s Finkel’s Adson’s Valgus Stress Varus Stress AP Drawer Sign PA Drawer Sign Deg. Deg. Deg. Deg. Deg. Sec. ROM Location C/TH Norm Deg. Pain TH/L Norm Deg. Pain Location FLX EXT LR RR LLF RLF 45 45 80 80 45 45 FLX EXT LR RR LLF RLF 90 30 30 30 30 30 L Norm L R Should Norm R Notes Elbow R Notes Wrist Norm L Notes ABD ADD FLX ER IR 150 30 150 40 90 FLX EXT PRO SUP 150 0 80 80 F E RD UD 60 70 20 30 FLX EXT IR ER 150 10 15 20 DF PF EV IN 20 40 20 30 100 30 40 20 90 50 FLX EXT AB DA IR ER