SAMPLE GENERAL EXAMINATION. Patient s Name Patient #: Date: Feet Normal Pronation Supination. Knees Normal Valgum Varum
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1 GENERAL MUSCULOSKELETAL POSTURE GAIT AND STATION NEURO-COORDINATION PALPATION SUBLUXATION / LAXITY Your : Feet Normal Pronation Supination Knees Normal Valgum Varum Pelvis Level Low Right Low Left Lumbar Lordosis Normal Increased Decreased Thoracic Kyphosis Normal Increased Decreased Scapulae Level Low Right Low Left Shoulder Height Level Low Right Low Left Cervical Lordosis Normal Increased Decreased Head Tilt Normal Right Left Degree Antalgia Cervical Thoracic Lumbar Degree Normal Gait Romberg s Balance WNL ABN Tandem Stance / Walk WNL ABN Mood/Affect WNL ABN Orientation to time/person/place (Y/N) Misalignment Asymmetry Crepitation Defects Tenderness Masses Effusions GENERAL EXAMINATION HEAD NECK SPINE RIB PELVIS RIGHT UPPER LEFT UPPER RIGHT LOWER LEFT LOWER OCC C1 C2 C3 C4 C5 C6 C7 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 Sac RSI LSI Ext CONSTITUTIONAL Age Gender Height Weight Temperature BP Rt / Lt / Pulse Respiration GENERAL APPEARANCE Development / Patient Build Body Habits Grooming Nutrition GENERAL EXAMINATION 1/2
2 SKIN Head and Neck WNL ABN C4 WNL ABN L1 WNL ABN Trunk WNL ABN C5 WNL ABN L2 WNL ABN Right Upper Extremity WNL ABN C6 WNL ABN L3 WNL ABN DERMATOMES Left Upper Extremity WNL ABN C7 WNL ABN L4 WNL ABN Right Lower Extremity WNL ABN C8 WNL ABN L5 WNL ABN Left Lower Extremity WNL ABN T1 WNL ABN S1 WNL ABN HEENT Cranial Nerves WNL ABN Eyes WNL ABN Ears WNL ABN Nose WNL ABN Throat WNL ABN RESPIRATORY Notes GASTROINTESTINAL Notes GENERAL OBSERVATIONS CARDIOVASCULAR Varicosities WNL ABN Palpation WNL ABN Edema WNL ABN Tenderness WNL ABN Auscultation of Carotid Arteries WNL ABN LYMPHATIC Neck WNL ABN Axillae WNL ABN Groin WNL ABN Other WNL ABN GENITOURINARY Notes GENERAL EXAMINATION : : 2/2
3 Your Antalgic Head Posture Absent Present Absent Present Neck Brace Absent Present Absent Present Abducted Arm (Bakody s) L R Neg Pos L R Neg Pos Drift Test L R Neg Pos L R Neg Pos Finger to Nose Test L R Neg Pos L R Neg Pos Slump Test Neg Pos Neg Pos Soto-Hall Test Neg Pos Neg Pos Lindner s Test L R Neg Pos L R Neg Pos L Hermitte s Test L R Neg Pos L R Neg Pos Brudzinski s Test Neg Pos Neg Pos Dejerine s Test Neg Pos Neg Pos Bicep s Reflex C5-C6 L R L R Brachioradialis Reflex C5-C6 L R L R Triceps Reflex C7 L R L R Hoffman s Test L R Absent Present L R Absent Present Hand Grasp C5-T1 L R L R *Deltoid C5 L R L R *Biceps C5-C6 L R L R *Wrist Extension C6 L R L R *Wrist Flexion C7 L R L R *Finger Extension C8 L R L R *Finger Abductors T1 L R L R *Finger Adductors T1 L R L R Cervical Compression Test L R Neg Pos L R Neg Pos Cervical Distraction Test L R Neg Pos L R Neg Pos Bakody s Test L R Neg Pos L R Neg Pos Reverse Bakody s Test L R Neg Pos L R Neg Pos Brachial Plexus Tension Test L R Neg Pos L R Neg Pos Shoulder Depressor Test L R Neg Pos L R Neg Pos *Cervical Circumference *Upper Arm Circumference L R L R *Lower Arm Circumference L R L R Cervical Flexion Cervical Extension Cervical Lateral Bending Right Cervical Lateral Bending Left Cervical Rotation Right Cervical Rotation Left *Supplemental as needed. CERVICAL EXAMINATION
4 *Supplemental as needed. Your LUMBOSACRAL EXAMINATION Antalgic Posture Absent Present Absent Present Minor s Sign Absent Present Absent Present Back Brace Absent Present Absent Present Ambulatory Aid Absent Present Absent Present Leg Pain L R Neg Pos L R Neg Pos Slump Test Neg Pos Neg Pos Seated Adams Test L R Neg Pos L R Neg Pos Lindner s Test L R Neg Pos L R Neg Pos Brudzinski s Test Neg Pos Neg Pos L Hermitte s Test L R Neg Pos L R Neg Pos Bechterew s Test L R Neg Pos L R Neg Pos SLR Test L R Neg Pos L R Neg Pos CSLR Test L R Neg Pos L R Neg Pos Kernig s Test L R Neg Pos L R Neg Pos Tripod Test L R Neg Pos L R Neg Pos Bragard s Test L R Neg Pos L R Neg Pos Fajersztajn s Test L R Neg Pos L R Neg Pos Homan s Test L R Neg Pos L R Neg Pos Kemp s Test L R Neg Pos L R Neg Pos Heel to Shin Test L R Neg Pos L R Neg Pos Patellar Reflex L2-L4 L R L R Achilles Reflex S1-S2 L R L R Babinski s Reflex L R Absent Present L R Absent Present *Iliopsoas T12-L3 L R L R *Quadriceps L2-L4 L R L R *Anterior Tibialis L4 L R L R *Extensor Hallucis Longus L5 L R L R *Peroneus Longus and Brevis S1 L R L R Fluid Motion Test L R Neg Pos L R Neg Pos Nachlas Test L R Neg Pos L R Neg Pos Femoral Stretch Test L R Neg Pos L R Neg Pos Yeoman s Test L R Neg Pos L R Neg Pos Hibb s Test L R Neg Pos L R Neg Pos Tandem Stance Neg Pos Neg Pos Standing Adams Test L R Neg Pos L R Neg Pos Neri s Bowing Test L R Neg Pos L R Neg Pos Knee Bends (5) L R L R Heel walking in Place L R L R Toe Raises L R L R *Upper Leg Circumference L R L R *Lower Leg Circumference L R L R Lumbosacral Flexion Lumbosacral Extension Lumbosacral Lateral Bending Right Lumbosacral Lateral Bending Left 25 25
5 Your UPPER EXAMINATION Handedness Right Handed Ambidextrous Left Handed Antalgic Posture Absent Present Absent Present Muscle Atrophy Absent Present Absent Present Deformity Absent Present Absent Present Edema Absent Present Absent Present Deltoid C5 L R L R Biceps C5-C6 L R L R Wrist Extensors C6 L R L R Wrist Flexors C7 L R L R Finger Extensors C8 L R L R Finger Abductors T1 L R L R Finger Adductors T1 L R L R *Upper Arm Circumference L R L R *Lower Arm Circumference L R L R Biceps DTR C5 L R L R Brachioradialis DTR C6 L R L R Triceps DTR C7 L R L R Hoffman s Reflex L R Absent Present L R Absent Present Apley s Superior Test L R Neg Pos L R Neg Pos Apley s Inferior Test L R Neg Pos L R Neg Pos Mazion s Test L R Neg Pos L R Neg Pos Cross-over Impingement Test L R Neg Pos L R Neg Pos Neer Impingement Test L R Neg Pos L R Neg Pos Hawkins-Kennedy Test L R Neg Pos L R Neg Pos Speed s Test L R Neg Pos L R Neg Pos Supraspinatus Test L R Neg Pos L R Neg Pos AC Stress/Shear Test L R Neg Pos L R Neg Pos Varus Stress Test L R Neg Pos L R Neg Pos Valgus Stress Test L R Neg Pos L R Neg Pos Cozen s Test L R Neg Pos L R Neg Pos Reverse Cozen s Test L R Neg Pos L R Neg Pos Mill s Test L R Neg Pos L R Neg Pos Reverse Mill s Test L R Neg Pos L R Neg Pos Tinel s Test L R Neg Pos L R Neg Pos Finklestein s Test L R Neg Pos L R Neg Pos Phalan s Test L R Neg Pos L R Neg Pos Reverse Phalan s Test L R Neg Pos L R Neg Pos *Supplemental as needed.
6 Your LOWER EXAMINATION Antalgic Posture Absent Present Absent Present Limp Absent Present Absent Present Muscle Atrophy Absent Present Absent Present Deformity Absent Present Absent Present Edema Absent Present Absent Present Iliopsoas T12-L3 L R L R Quadriceps L2-L4 L R L R Heel walking in Place L4-L5 L R L R Toe Raises S1-S2 L R L R *Upper Leg Circumference L R L R *Lower Leg Circumference L R L R Patellar DTR L4 L R L R Achilles DTR S1 L R L R Babinski s Reflex L R Absent Present L R Absent Present Anvil Test L R Neg Pos L R Neg Pos Patrick Test L R Neg Pos L R Neg Pos Thomas Test L R Neg Pos L R Neg Pos Hibb s Test L R Neg Pos L R Neg Pos Anterior Draw Test L R Neg Pos L R Neg Pos Posterior Draw Test L R Neg Pos L R Neg Pos Valgus Stress Test L R Neg Pos L R Neg Pos Varus Stress Test L R Neg Pos L R Neg Pos Slocum External Rotation Test L R Neg Pos L R Neg Pos Slocum Internal Rotation Test L R Neg Pos L R Neg Pos Hughston s Posterior Medial L R Neg Pos L R Neg Pos Hughston s Posterior Lateral L R Neg Pos L R Neg Pos Patellar Ballottement Test L R Neg Pos L R Neg Pos McMurry s Test L R Neg Pos L R Neg Pos Hughston s Plica Test L R Neg Pos L R Neg Pos Noble s Test L R Neg Pos L R Neg Pos Homan s Test L R Neg Pos L R Neg Pos Ankle Anterior Draw Sign L R Neg Pos L R Neg Pos Ankle Posterior Draw Sign L R Neg Pos L R Neg Pos Valgus Stress Test L R Neg Pos L R Neg Pos Varus Stress Test L R Neg Pos L R Neg Pos Morton s Test L R Neg Pos L R Neg Pos *Supplemental as needed.
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