Name:__________________________________ X-ray #:_______ Case # ________
PRE POST POST POST Sitting: PRE POST POST POST
Date ______ ______ ______ ______ Klienes Rt: ______ ______ ______ ______
Blood Pressure: ___/___ ___/___ ___/___ ___/___ Lt: ______ ______ ______ ______
Temp: ______ ______ ______ ______
Pulse ______ ______ ______ ______ Valsalva Rt: ______ ______ ______ ______
Lt: ______ ______ ______ ______
Sitting PRE POST POST POST
Cervical Distr. ______ ______ ______ ______ Becheterews Rt: ______ ______ ______ ______
Cervical Comp ______ ______ ______ ______ Lt: ______ ______ ______ ______
Foraminal Com Rt: ______ ______ ______ ______ Both ______ ______ ______ ______
Lt: ______ ______ ______ ______
Shoulder Comp Rt: ______ ______ ______ ______ Supine: PRE POST POST POST
Lt: ______ ______ ______ ______ Lasegue's Sign: Rt: ______ ______ ______ ______
Cervical ROM Fl ______ ______ ______ ______ Lt: ______ ______ ______ ______
Ex ______ ______ ______ ______ Braggard Test: Rt: ______ ______ ______ ______
LL ______ ______ ______ ______ Lt: ______ ______ ______ ______
RL ______ ______ ______ ______ Patrick-Fabere: Rt: ______ ______ ______ ______
LR ______ ______ ______ ______ Lt: ______ ______ ______ ______
RR ______ ______ ______ ______ Soto-Hall: ______ ______ ______ ______
Reflexes: PRE POST POST POST Prone PRE POST POST POST
Bicepital Rt: ______ ______ ______ ______ Ely-Heal Test: Rt: ______ ______ ______ ______
Lt: ______ ______ ______ ______ Lt: ______ ______ ______ ______
Brachial Rt: ______ ______ ______ ______ Leg Length: Rt: ______ ______ ______ ______
Lt: ______ ______ ______ ______ Lt: ______ ______ ______ ______
Triceps Rt: ______ ______ ______ ______
Lt: ______ ______ ______ ______ Hand Strength: Rt: ______ ______ ______ ______
Pateller Rt: ______ ______ ______ ______ Rt: ______ ______ ______ ______
Lt: ______ ______ ______ ______ Rt: ______ ______ ______ ______
Achilles Rt: ______ ______ ______ ______ Lt: ______ ______ ______ ______
Lt: ______ ______ ______ ______ Lt: ______ ______ ______ ______
Pinwheel: PRE POST POST POST Lt: ______ ______ ______ ______
C6 (Thumb & 1st) Rt: ______ ______ ______ ______ Standing:
Lt: ______ ______ ______ ______ Thoraco-Lumbar Fle ______ ______ ______ ______
C7 (Middle) Rt: ______ ______ ______ ______ ROM Ext ______ ______ ______ ______
Lt: ______ ______ ______ ______ RL ______ ______ ______ ______
C8 (4th &5th) Rt: ______ ______ ______ ______ LL ______ ______ ______ ______
Lt: ______ ______ ______ ______ RR ______ ______ ______ ______
T1 (Med Forarm) Rt: ______ ______ ______ ______ LR ______ ______ ______ ______
Lt: ______ ______ ______ ______
L2 (Ant. Thigh) Rt: ______ ______ ______ ______ Bi-Lateral Wt. Tot ______ ______ ______ ______
Lt: ______ ______ ______ ______ Rt: ______ ______ ______ ______
L4 (Med Tibia) Rt: ______ ______ ______ ______ Lt: ______ ______ ______ ______
Lt: ______ ______ ______ ______
L5 (Lat. Tibia) Rt: ______ ______ ______ ______
Lt: ______ ______ ______ ______
S1 (Lat. Foot) Rt: ______ ______ ______ ______
Lt: ______ ______ ______ ______
Notes:_________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________