Biomechanical Assessment Report

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BIOMECHANICAL ASSESSMENT REPORT
PATIENT NAME:
DATE OF ASSESSMENT:
ASSESSMENT PROFESSIONAL (Name & Designation):
PATIENT HISTORY:
(Medical condition,
symptoms, chief complaints):
BIOMECHANICAL & GAIT ANALYSIS ASSESSMENT
FOOT (Type or Appearance)
NWB
WB
ANKLE R.O.M.
NWB
WB
High Arch
L / R
L / R
Adequate
L / R
L/R
Medium Arch
L / R
L / R
Limited
L / R
L/R
Low Arch
L / R
L / R
SUBTALAR JOINT ROM
KNEE POSITION
Hypermobile
L / R
Normal
L / R
Within Normal Limits
L / R
Genu Varum
L / R
Limited/Restricted
L / R
Genu Valgum
L / R
Tibial Varum
L / R
MIDTARSAL JOINT ROM
CALCANEAL POSITION NON-WEIGHT BEARING
Hypermobile
L / R
Normal
L / R
Normal
L / R
Varus
L / R
Restricted
L / R
Valgus
L / R
GAIT ANALYSIS
KNEE ALIGNMENT:
Rotational:
MIDTARSAL FUNCTION AT MIDSTANCE
Internal
L/R
Normal
L / R
External
L/R
Pronated
L / R
Supinated
L / R
Frontal:
Genu Varum
L/R
Valgum
L/R
Recurvatum
L/R
st
1
RAY
LEG LENGTH DISCREPANCY
Position
Plantarflexed
L / R
Short By L ____ mm/inches
R ____ mm/inches
Normal
L / R
Extended
L / R
Functional
Structural
HALLUX Range Of Motion
ANGLE OF GAIT
Average
L / R
Within Normal Limits
L / R
Limitus
L / R
Abducted
L / R
Rigidus
L / R
Adducted
L / R
Functional Hallux Limitus
L / R
TOE POSITIONS
CALCANEAL POSITION WEIGHT BEARING
Hallux Abducto Valgus
L / R
Normal
L / R
Claw/ Hammer Toe
L / R
Varus
L / R
Straight (within normal limits)
L / R
Valgus
L / R
(1
2
3
4
5 )
TREATMENT RECOMMENDATIONS:

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