Patient Health History - Intake Form Page 5
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8Office Use Only --- Do Not Write Below
Physical Exam
Vitals
HT:
WT:
HR:
BP:
R:
Range of Motion
DTR's
Right
Left
Bicep
_______ / 2
_______ / 2
C-Spine
L-Spine
Patella
_______ / 2
_______ / 2
F. Flexion
_______ / 45
_______ / 80
Achilles
_______ / 2
_______ / 2
Extension
_______ / 45
_______ / 30
Strength
R. Lateral
_______ / 45
_______ / 40
UE
_______ / 5
_______ / 5
L. Lateral
_______ / 45
_______ / 40
LE
_______ / 5
_______ / 5
R. Rotation
_______ / 60
_______ / 45
Sensory
L. Rotation
_______ / 60
_______ / 45
R. SLR
_______ / 60
UE
L. SLR
_______ / 60
LE
Orthopedic Exam
Elbow
Shoulder
Medial Epicondylitis
+
-
Neer Impingement Sign/Rotator Cuff
+
-
Pain Resisted Wrist Flexion
+
-
Pain or Resisted Abduction/Supraspinatus
Lateral Epicondylitis
+
-
Pain or Resisted Lateral Rotation (infraspinatus)
+
-
Firm Hand Grasping
+
-
Medial Rotation (subscapularis)
+
-
Pain Resisted Wrist Extension
+
-
Elbow Flexion (Biceps)
+
-
Supination (Biceps)
Knee
+
-
Valgus Stress Test (Medial Collateral Ligament)
+
-
Varus Stress Test (Lateral Collateral Ligament)
+
-
McMurray Test (Medial Meniscus)
(Extension = Lateral Movement)
Notes:
Physician Signature:
Date:
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