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Functional Exam

How many visits so far?
Today's Date
First Name
Last Name
Test Number
NP
P1
P2
P3
P4
Re-Eval
Complaints?
Neck Pain - Mild
Neck Pain - Moderate
Neck Pain - Severe
Back Pain - Mild
Back Pain - Moderate
Back Pain - Severe
Upper Back Pain - Mild
Upper Back Pain - Moderate
Upper Back Pain - Severe
Mid Back Pain - Mild
Mid Back Pain - Moderate
Mid Back Pain - Severe
Headaches - Daily
Headaches - Twice Weekly
Headaches - Once Weekly
Headaches - Occasional
Migraines - Daily
Migraines - Twice Weekly
Migraines - Once Weekly
Migraines - Occasional
Fatigue - Mild
Fatigue - Moderate
Fatigue - Severe
Poor Sleep Mild
Poor Sleep Moderate
Poor Sleep Severe
Stress - Mild
Stress - Moderate
Stress - Severe
Other
Please Specify:
Cervical Flexion
60
55
50
45
40
35
30
25
20
0
Cervical Flexion Severity
0
0+
1
1+
2
2+
3
3+
Cervical Extension
70
65
60
55
50
40
30
25
20
15
10
0
Cervical Extension Severity
0
0+
1
1+
2
2+
3
3+
Cervical Left Lateral Flexion
45
40
35
30
25
20
15
10
5
0
Cervical Left Lateral Flexion Severity
0
0+
1
1+
2
2+
3
3+
Cervical Right Lateral Flexion
45
40
35
30
25
20
15
10
5
0
Cervical Right Lateral Flexion Severity
0
0+
1
1+
2
2+
3
3+
Cervical Left Rotation
90
85
80
70
60
50
40
30
20
10
0
Cervical Left Rotation Severity
0
0+
1
1+
2
2+
3
3+
Cervical Right Rotation
90
85
80
70
60
50
40
30
20
10
0
Cervical Right Rotation Severity
0
0+
1
1+
2
2+
3
3+
Left Levator Scapulae
0
0+
1
1+
2
2+
3
3+
Right Levator Scapulae
0
0+
1
1+
2
2+
3
3+
Left Modified Spurling's
0
0+
1
1+
2
2+
3
3+
Right Modified Spurling's
0
0+
1
1+
2
2+
3
3+
Left Adson's
0
0+
1
1+
2
2+
3
3+
Right Reverse Adson's
0
0+
1
1+
2
2+
3
3+
Right Adson's
0
0+
1
1+
2
2+
3
3+
Left Reverse Adson's
0
0+
1
1+
2
2+
3
3+
Left Costoclavicular
0
0+
1
1+
2
2+
3
3+
Right Costoclavicular
0
0+
1
1+
2
2+
3
3+
Right Wrights
0
0+
1
1+
2
2+
3
3+
Left Wrights
0
0+
1
1+
2
2+
3
3+
+ve TOS Symptoms
None
Mild
Moderate
Severe
Left Deltoid (shoulder)
5
4.5
4
Right Deltoid (shoulder)
5
4.5
4
Left Bicep
5
4.5
4
Right Bicep
5
4.5
4
Left Tricep
5
4.5
4
Right Tricep
5
4.5
4
Left Wrist Extension
5
4.5
4
Right Wrist Extension
5
4.5
4
Left Hip
5
4.5
4
Right Hip
5
4.5
4
Left Knee Extension (thigh)
5
4.5
4
Right Knee Extension (thigh)
5
4.5
4
Left Knee Flexion (hamstring)
5
4.5
4
Right Knee Flexion (hamstring)
5
4.5
4
Romberg's Sway Left
0
0+
1
1+
2
2+
3
3+
Romberg's Sway Right
0
0+
1
1+
2
2+
3
3+
Romberg's Sway Anterior (forward)
0
0+
1
1+
2
2+
3
3+
Romberg's Sway Posterior (backward)
0
0+
1
1+
2
2+
3
3+
Fakuda's Translation
0 cm
20 cm
30 cm
40 cm
50 cm
60 cm
70 cm
80 cm
90 cm
100 cm
110 cm
120 cm
130 cm
140 cm
150 cm
160 cm
170 cm
180 cm
190 cm
200 cm
Fakuda's Rotation Direction
Left
Right
None
Fakuda's Rotation (Degree's)
0
5
10
20
30
40
45
50
60
70
80
85
90
100
110
120
130
140
150
Fakuda's How Many Steps Completed?
0
5
10
15
20
25
30
35
40
45
50
Fakuda's How Unstable?
Normal
Mild
Moderate
Severe
Hamstring Tightness
0
0+
1
1+
2
2+
3
3+
Unable due to pain
Thoraco-Lumbar Flexion
90
85
80
70
60
50
40
30
20
10
5
0
Thoraco-Lumbar Flexion Severity
0
0+
1
1+
2
2+
3
3+
Thoraco-Lumbar Extension
20
15
10
5
0
Thoraco-Lumbar Extension Severity
0
0+
1
1+
2
2+
3
3+
Thoraco-Lumbar Left Lateral Flexion
35
30
25
20
15
10
5
0
Thoraco-Lumbar Left Lateral Flexion Severity
0
0+
1
1+
2
2+
3
3+
Thoraco-Lumbar Right Lateral Flexion
35
30
25
20
15
10
5
0
Thoraco-Lumbar Right Lateral Flexion Severity
0
0+
1
1+
2
2+
3
3+
Thoraco-Lumbar Left Rotation
45
40
35
30
25
20
15
10
5
0
Thoraco-Lumbar Left Rotation Severity
0
0+
1
1+
2
2+
3
3+
Thoraco-Lumbar Right Rotation
45
40
35
30
25
20
15
10
5
0
Thoraco-Lumbar Right Rotation Severity
0
0+
1
1+
2
2+
3
3+
Left Standing Kemps
0
0+
1
1+
2
2+
3
3+
Right Standing Kemps
0
0+
1
1+
2
2+
3
3+
Milgram's + Cervical Compression
Easier
Same
Slightly Harder
Moderately Harder
Impossible
Unable due to pain
Left Nachlas
0
0+
1
1+
2
2+
3
3+
Left Ely's
0
0+
1
1+
2
2+
3
3+
Left Hibb's
0
0+
1
1+
2
2+
3
3+
Right Nachlas
0
0+
1
1+
2
2+
3
3+
Right Ely's
0
0+
1
1+
2
2+
3
3+
Right Hibb's
0
0+
1
1+
2
2+
3
3+
Additional Comments
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