ADMIN
Patient Initials
First Name
Last Name
Clinic date
-
Month
-
Day
Year
Date Picker Icon
Upload of Pain Chart
Upload of Hxx Timeline
Additional Upload
Back
Next
Individual Details
DOB
-
Month
-
Day
Year
Date Picker Icon
Age
Years old
Dominance
Left
Right
Ambidextrous
Occupation
Home
Activity/Exercise Hxx
Full informed consent to Treat gained
Yes
No
Back
Next
History
Primary Complaint
Secondary Complaint
Tertiary Complaint
Primary Complaint
Site
Onset
Character
Radiations
Aggravating
Easing
Time/Temporal profile
VAS Oxx
0
1
2
3
4
5
6
7
8
9
10
VAS Current
0
1
2
3
4
5
6
7
8
9
10
Daily Pattern/24 hour pattern
AM
PM
Night Pain
Yes
No
Occasionally
Other HCP's seen
Notes
Back
Next
Past History
Investigations
Date
Type
Summary
Diagnosis
1
2
3
4
5
6
Traumas
Date
Type
Summary
Diagnosis
1
2
3
4
5
6
Surgeries/Interventions
Date
Type
Summary
Diagnosis
1
2
3
4
5
6
Medication
Type
Dose
Since
1
2
3
4
5
6
Notes
Back
Next
Systemics
Sleep Hours
1
2
3
4
5
6
7
8
9
10
11
12
Stress Levels
1
2
3
4
5
6
7
8
9
10
Night Pain
Yes
No
General
Weight Loss/Gain
Allergies
Thyroid
Diabetes
Rheumatoid
Cancer
Osteoporosis
GIT
CVS
Vent
Neuro
GIU
Dermatoloical
Obs/Gyne
Family Health Hxx
Back
Next
ASSESSMENT
TOP TIER ASSESSMENT
Height
Weight
RHR
BP
BMI
Morphology
Endomorph
Ectomorph
Mesomorph
Beightons Scale
Please Select
0
1
2
3
4
5
6
7
Breakouts used
Neurological
EENT
Heart Lungs Abdominal
Cervicothoracic
Lumbopelvic
Shoulder
Elbow
Wrist/Hand
Hip
Knee/Thigh
Ankle/Foot
TMJ
Observations
Passive Posture
Left
Right
OA
Cervical
Thoracic
Ribs
Lumbar
Scapular
Iliac Crest
ASIS
PSIS
Hips
Knees
Ankle
Functional Screening
Left
Right
Deep squat - shoulders 90°abduction / ER if possible - if not identify alternate. Heels on floor. Full squat with trunk // to tibia
Single Leg Squat
SL Heel raise - Bilateral
SL Gastroc Heel raises- unilateral
-
15 without fatigue
- no more than difference of 3 L to R
SL Soleus Heel raises
SL Soleus Heel raises Unillateral
-
15 without fatigue
- no more than difference of 3 L to R
Press up
Front Plank
Side Plank
Single Leg Drop from Box
Sit to stand
-
Concentric and eccentric – no arm support. Knee height
- Reps in 60 sec
Sit to stand - unilateral
-
Concentric and eccentric – no arm support. Knee height
- Reps in 60 sec
Step Ups
- Knee height
Single leg stance balance Eyes open
- hip and knee flexed to 90°
Single leg stance balance Eyes Closed
- hip and knee flexed to 90°
In line lunge
- Knee flexed and opposite heel touching
- back straight"
Lunge
- Tibia perpendicular
- 10 without fatigue"
Standing forward hop
-
Start feet together, measure distance (for LL power)"
Decline squat - unilateral
- 25°decline
- aim to get to 90° knee flexion, 10 times"
Decline squat - bilateral
-if unilateral not appropriate
- 25°decline, aim to get to 90° knee flexion, 10 times
Bilateral Bridge
-
Aim for thigh and trunk to be parallel
SL Bridge
- Aim for thigh and trunk to be parallel, contra-knee extended
SL Leg Press
- Start knee 90°F, aim for 1.25x body weight
Bilateral leg press -if unilateral not appropriate
-
Start knees 90°F, aim for 1.5x body weight
Abdominal
- knees flexed, elbows extended
- semi curl-up (pillow under head) touch patella
- Number of reps.
Back
Next
CERVICOTHORACIC
Screening
VBI Clearing
CN Testing
Visceral exclusion
Dizzyness
Diploplia
Dysarthria-
Dysphagia-
Drop attacks-
Nausea
Canadian Csp Rules
Sitting posture
Neutral
Lordotic
Slumped
Sway
Observations
Left
Right
Csp Tilt
Csp Rotation
Head Carridge
Csp Lordosis Hyper/Hypo
High Shouler
Tsp Scoliosis
Tsp Kyphosis Hyper/Hypo
Adams Sign
AROM - PROM - OP
AROM Left
PROM Left
OP Left
AROM Right
PROM Right
OP Right
OA
AA
Csp Flexion (50)
Csp Extension (80)
Csp Lateral Flexion (45)
Csp Rotation (80)
CTJ
1st Rib
Tsp Flexion (20-45)
Tsp Extension (25-45)
Tsp Lateral Flexion (20-40)
Tsp Rotation (35-50)
TLJ
Shoulder Flex (180)
Shoulder Ext (50)
Shoulder Abd (180)
Shoulder Add (30)
Shoulder IR (90)
Shoulder ER (80)
Scaupulohumeral rhythm
SCJ
ACJ
Palpation
Left
Right
Skin (masses, Temp)
Lymph nodes
Temporalis
Masseter
TMJ
Scalenes
SCM
Lev Scap
Traps
Rhomboids
SubOcc
Posterior Csp mm
Trachea mobility
Thyroid Gland
Rotator Cuff
Spinal Segments
Left
Right
C0
C1
C2
C3
C4
C5
C6
C7
T1
T2
T3
T4
T5
T6
Resisted Isometric
Left
Right
Flexion
Extension
Lateral Flexion
Rotation
Peripheral Joint Scan (tick if positive for Concordant sign)
TMJ
Shoulder
Elbow
Wrist and Hand
Neurological Screening (tick if AD in Myotome, Sensory Screening or DTR) See Neurological breakout for details.
NAD
Myotome AD
DTR AD
Sensory AD
Functional Assessment
Tick any abnormalities/difficulties
Breathing
Swallowing
Looking up at Ceiling
Looking down at Shoe Laces
Shoulder check
Tuck chin in
Poke chin out
Neck Strength (Approx 30% BW)
Parathesia
Functional Strength Testing
Supine Lying (lift head, chin tucked
6-8 reps (functional)
3-5 reps (functionally fair)
1-2 reps (functionally poor)
0 reps (non-functional)
Lift head, keeping chin tucked in (neck flexion)
Special tests - PPT
Screening
Left
Right
Valsalva
Cervical Compression
Maximal Compression
Cervical Distraction
Soto Hall
Julls Test
Brachial Stretch
Shoulder Depression
Vertebral Artery Screening
Left
Right
Cervical Artery Quadrent
Thoracic Outlet
Left
Right
Edens
Wrights
Adsons
Roo’s
Cervical Instability Test
Left
Right
Sharp-Purser Test
Transverse Ligamanet Stress Test
Anterior Shear Test
Lateral Shear Test
Vertigo and Dizziness
Left
Right
Romburg
Hallpike
Functional Testing
Functional Testing
Left
Right
Craniocervial Flexion Test 10x 10mmhg increase
Supine Lying
Prone Lying
Side Lying
Supine Lying
Neck Strength 30% of BW
PPMs
PPMs
NDI
Option 2
Option 3
Notes
Back
Next
LUMBOPELVIC
Screening
Hip Cleared
Knee Cleared
Visceral exclusion
Bowel/Bladder Change
Saddle Parathesia
Standing Passive Posture
Neutral
Lordotic
Slumped
Sway
Sitting posture
Neutral
Lordotic
Slumped
Sway
Observations
Observations
Left
Right
NormalLordosis
HypoLordosis
HyperLordosis
FlatBack
SwayBack
Scoliosis
Anterior Tilt
Posterior Tilt
PSIS Elevation
Postural Asymmetry
Heel walk (L4)
Toe Raise (S1)
Squat and Rise
Squat and 3 bounce
Gait
AROM - PROM - OP
AROM Left
PROM Left
OP Left
AROM Right
PROM Right
OP Right
Lsp Flexion (60)
Lsp Extension (30)
Lateral Flexion (25)
Rotation (10)
SIJ Flexion/Extension (0-10)
SIJ External/Internal (5-10)
SIJ Sheer
Lumbopelvic Rhythm
Palpation
Left
Right
Abdomen
Inguinal Lymph Nodes
Skin Temp
Pubic Symphasis
ASIS
Iliac Crest
Paraspinal MM
Quadratus Lumborum
Sciatic Notch
PSIS
Ischial Tuberosities
Hamstrings
TFL
Greater trochanter
Piriformus
Sacrotuberous Lig
SIJ
Sacrospinous Lig
Glute Max
Glute Med
Quadriceps
Gastro-Soleus
Spinal Segments
Left
Right
T12
L1
L2
L3
L4
L5
S1
Sacrum
Coxxyx
SIJ
Resisted Isometric
Left
Right
Flexion
Extension
Lateral Flexion
Rotation
Movement Assessment
Normal
Rotation
Flexion
Extension
BW Squats
Normal
Tsp Dominant
4 Point Pelvic tilt
Normal
Pelvic Rotation
Lsp Flexion
4 Point Rock Back
Normal
Rotation
4 Point Shoulder Flexion
Special Tests - PPTs
General
Left
Right
LLD
Adams Sign
SIJ Testing
Left
Right
Gillete/Fixation
Distraction
Compresion
Thigh Thrust
Sacral Thrust
Belt test
Instability Tests
Left
Right
Specific Lumbar Spine Torsoin Test
Farfan Torsoin Test
Gillete/Fixation
Lateral Lumbar Spinal Stability
Anterior Lumbar Spinal Stability
Posterior Lumbar Spinal Stability
Joint Dysfunction
Very Satisfied
Satisfied
Somewhat Satisfied
Not Satisfied
Stork Test
Quadrent Test
Intermittent Claudication
Positive
Negative
Bike Test
DVT Screening
Positive
Negative
Homans
Meningitis
Positive
Negative
Brudzinskis
Other Test
Left
Right
Trendelenburg
Ober
Scour
SLR Active
Anvil
Allis Sign
FABER
FADIR
Functional Testing
DYNAMIC ABDOMINAL ENDURANCE 12cm from fingertips reps until fatigue or compensation. Reps as measure
Reps
ISOMETRIC ABDOMINAL ENDURANCE TEST 12cm from fingertips reps until fatigue or compensation.
Please Select
5 = Hands behind head, Scapula off floor, 30sec hold
4 = Hands across chest. 20sec hold
3 = Arms straight. 15sec hold
2 = Arms straight. Top of scapula off table. 10sec
1 = Head off table
MCGILL ISOMETRIC ABDOMINAL TEST Knees bent. Feet fixed. Hands across chest. 60 flex at hips. For time
Seconds held
DYNAMIC EXTENSOR ENDURANCE TEST Prone. 30deg flex. Reps as Measure
Reps
ISOMETRIC EXTENSOR TEST Prone. 30deg flex.
5 = Hands behind head, 30sec hold
4 = Hands across chest. 20sec hold
3 = Arms straight. 15sec hold
2 = Arms straight. 10sec
1 = Slight contraction
Select one
BIERING-SORENSON EXTENSOR HOLD Prone 30deg flex.
Seconds
DOUBLE LEG LOWER TEST
5 = 0-15 from table before tilt
4 = 16-45
3 = 46-75
2 = 75-90
1 = Unable
Select one
ISOMETRIC OBLIQUE TEST Supine. Flat. Flex and rotate to touch other fingertips.
5 =30sec hold
4 = 20sec hold
3 = 15sec hold
2 =10sec
1 = Slight contraction
Select one
DYNAMIC OBLIQUE TEST
Reps
SIDE BRIDGE?HORIZONTAL SUPPORT Male 65% Extensor Time. Female 39% Extensor Time
Back
Next
Shoulder Breakout
Clearing
Modified Sharp-Purser
Csp
VBI
Visceral Exclusion
Standing Posture
Neutral
Lordotic
Slumped
Sway
Observation
LHS
RHS
Head Tilt
Head Rotation
Shoulder high
Scapula
Scapula Winging
Shoulder Rounded
Scapula Rotated Medial
Scapula Rotated Lateral
Humerus IR
Humerus ER
GH Sulcus sign
AC Step Defect
Scapula
GH
Scapulocostal
ACJ
SCJ
AROM - PROM - OP
AROM Left
PROM Left
OP Left
AROM Right
PROM Right
OP Right
Flex (180)
Ext (50)
ABd (180)
ADd (35)
IR (90)
ER (80)
Scapulocostal rythmn
ACJ
SCJ
Palpation
LHS
RHS
Notes
Upper Trap
Middle Trap
Lower Trap
Rhomboids
Tsp
Ribs 1-9
Lev Scap
Scalenes
Thoracic Outlet
Csp
Supraspinatus
Infraspinatus
Subscapularis
Teres Minor
Teres Major
Lat Dorsi
Pec Major
Pec Minor
ACJ
ACJ Step Defect
SCJ
Rot Cuff Post
Rot Cuff Ant
Rot Cuff Superior
Serratus Anterior
Triceps Brachi
Biceps Brachi
Bicepital Groove
Deltoid
Deltoid Tuberosity
Coracoid Process
Coracobrachialis
PPT - Special Testing
Screening
LHS
RHS
Notes
Apley Inferior
Codman Arm Drop
Dugas
Impingement
LHS
RHS
Notes
Hawkins Kennedy
Impingement sign
Painful Arc
Passive Neers
Bicep Tendonitis
LHS
RHS
Notes
Yergasons
Speeds
Bicepital Instability test
Empty Can
Labral Tear
LHS
RHS
Notes
Hyperabduction
Clunk
Crank
Obrians
Instability
LHS
RHS
Notes
Anterior Apprehension
Posterior Drawer
Load and Shift
Faegans
Pulses
LHS
RHS
Notes
Carotid
Auxillary
Brachial
Radial
Back
Next
Elbow Breakout
Observation
LHS
RHS
Notes
Antalgia
Skin
Asymmetry
Head tilt
Head rotation
Shoulder height
Shoulder rounded
Humerus rotated
Elbow flexed
Elbow hyperextended
Valgus forearm
Varus forearm
Forearm pronated
Forearm supinated
Han/finger deformity
Girth
LHS
RHS
Notes
Mid Arm
Elbow
Mid Forearm
ROM
AROM Left
PROM Left
OP Left
AROM Right
PROM Right
OP Right
Flexion (150)
Extension (0)
Supination (90)
Pronation (90)
Joint Play
LHS
RHS
Notes
Ulnohumeral
Radiohumeral
Pronimal Radio Ulnar
Palpation
LHS
RHS
Notes
Medial Epicondyle
Ulnar Grove
Medial Colateral Ligament
Common Flexor Tendon
Flexor Carpi Ulnaris
Palmaris Longus
Flexor Carpi radialis
Pronator teres
Biceps tendon
Head of Radius
Radial Tunnel
Lateral Epicondyle
Lateral colateral ligament
Lateral supracondylar ridge
Common extensor tendon
Anconeus
Brachioradialis
Extensor carpi ulnaris
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor digitorum
Supinator
Triceps tendon
Triceps brachii
Olecranon
Olecranon bursa
Cubital fossa
Brachialis
PPT - Special Testing
Instability
LHS
RHS
Notes
Valgus Stress (0)
Valgus Stress (30)
Varus Stress (0)
Varus Stress (30)
Medial Epicondylitis
LHS
RHS
Notes
Reverse Cozen's
Reverse Mill's
Reverse book lift
Lateral Epicondylitis
LHS
RHS
Notes
Book lift
Cozen's
Mill's
Kaplan's
Neuropathy
LHS
RHS
Notes
Tinel's Elbow
Tinel's Wrist
Elbow flexion test
Pronator stretch test
Pulses
LHS
RHS
Notes
Carotid
Auxillary
Brachial
Radial
Back
Next
Wrist/Hand Breakout
Observation
LHS
RHS
Notes
Head position
Shoulder position
Elbow position
Hand pronated/supinated
Fingers flexed/extended
Boutonniere deformity
Swan neck deformity
Mallet finger
Heberden’s nodes
Bouchard’s nodes
AROM - PROM - OP
AROM Left
PROM Left
OP Left
AROM Right
PROM Right
OP Right
Wrist Flexion (80°)
Wrist Extension (70°)
Wrist Ulnar flexion (30°)
Wrist Radial flexion (20°)
MP Flexion (90°)
MP Extension (40°)
MP Abduction (20°)
MP Adduction (20°)
PIP Flexion (70°)
PIP Extension (0°)
DIP Flexion (80°)
DIP Extension (20°)
Thumb MP exion (60°)
Thumb MP extension (20°)
Thumb IP flexion (90°)
Thumb IP extension (20°)
Distal Radioulnar Joint Play
Individual Carpals Joint Play
Palpation
LHS
RHS
Notes
Wrist flexors
Pronator teres
Wrist extensors
Supinator
Thumb extensors
Interossei
Thenar pad
Hypothenar pad
Carpal tunnel
Tunnel of Guyon
Anatomic snuff box
Metacarpals
Thumb (#1)
Index finger (#2)
Middle finger (#3)
Ring finger (#4)
Little finger (#5)
Scaphoid
Lunate
Triquetrum
Pisiform
Hamate
Capitate
Trapezoid
Trapezium
Ulnar/radial styloids
Triangular complex
Collateral ligaments
PPT - Special Testing
Back
Next
Submit
Should be Empty: