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Assessment Setup Demographics

Client Name:

Medical Record Number:

Employer:

Occupation:

Job Title:

Referring Doctor:

Other Doctor:

Other Doctor:

Diagnosis:

Evaluator:

Claims Adjustor:

Case Manager:

Attorney:

Gender: Male Female

Date of Birth:

Date of Eval:

Date of Injury:

Date of Surgery 1:

Date of Surgery 2:

Date of Surgery 3:

Date of Surgery 4:

Other:

Time In:

Time Out:

Basic Diagnostics Anthropometry

Height: inches

Weight: pounds

Dominance: Right Handed Left Handed

Ambidextrous

Pre-Evaluation Diagnostics

Resting Heart Rate: bpm

Resting Blood Pressure: mmHg

Resting Respiratory Rate: /min

Limiting Factors

Aerobic Limiting Factor: bpm

Weight Limiting Factor: pounds

Pain Rating

Following the presentation of the OccuPro

Functional Pain Scale did this client report that they

understood the pain scale?

Present Functional Pain Level: 0 1 2 3 4 5 6 7 8 9 10

Average Functional Pain Level: 0 1 2 3 4 5 6 7 8 9 10

Worst Functional Pain Level: 0 1 2 3 4 5 6 7 8 9 10

Least Functional Pain Level: 0 1 2 3 4 5 6 7 8 9 10

Following this client's report of their present,

average, worst and least pain did they report a

reliable level of pain prior to functional testing based

on OccuPro Functional Pain Scale

History of Present Condition

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Past Medical History

Present Status

Medications

Assessment Purpose

Job Demand Analysis Vocational Status

Current Work Status: Off at Work Light/Modified Duty Work Full Time Light/Modified Duty Work Part Time Full Duty Work Part Time Full Duty Work Full Time

Physical Demands Obtained From: On-Site Job Demands Analysis Job Description Dictionary of Occupational Titles Client Verbal Discussion with Employer

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Vocational Status:

The physical demands of the job should be documented on the Job Demands Match worksheet.

Musculoskeletal Testing

Posture

Palpation

Reflexes

Cervical ROM

Goniometric Measurements (Degrees or Percentage)

Cervical Flexion: °

Cervical Extension: °

Right Cervical Rotation: °

Left Cervical Rotation: °

Right Cervical Lat Flexion: °

Left Cervical Lat Flexion: °

Inclinometric Measurements

Cervical Flexion (60°)

+/-10 % or 5°

Max Angle

Calvarium Angle

T1 ROM

Angle

Cervical Extension (75°)

+/-10 % or 5°

Max Angle

Calvarium Angle

T1 ROM

Angle

Cervical Ankylosis in Lateral Bending:

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Cervical Left Rotation (80°)

+/-10 % or 5° Rotation Angle:

Max Angle

Cervical Right Rotation (80°)

+/-10 % or 5° Rotation Angle:

Max Angle

Cervical Ankylosis in Rotation:

Lumbar ROM

Goniometric Measurements (%)

Trunk Flexion:

Trunk Extension:

Right Trunk Rotation:

Left Trunk Rotation:

Right Trunk Lat Flexion:

Left Trunk Lat Flexion:

Inclinometric Measurements

Lumbar Flexion (60°) T12 ROM

+/- 10% or 5° Sacral ROM

Max Angle Flexion Angle

Lumbar Extension (25°) T12 ROM

+/- 10% or 5° Sacral ROM

Max Angle Angle

Straight Leg Rising (SLR), Left

+/- 10 % or 5° SLR (Left)

Straight Left Rising (SLR), Right

+/- 10% or 5° SLR (Right)

Straight Leg Rising (SLR), Validity

SLR Validity Midsacrum

Max Angle

Lumbar Left Lateral Bending (25°) T12 ROM

+/- 10% or 5° Sacral ROM

Max Angle Angle

Lumbar Ankylosis in Lateral Bending

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Thoracic ROM

Angel of Minimum Kyphosis T1 Reading

+/- 10% or 5° T12 Reading

Angle

Thoracic Flexion (50°) T1 Reading

+/- 10% or 5° T12 Reading

Max Angle Angle

Thoracic Flexion Repro(50°) T1 Reading

+/- 10% or 5° T12 Reading

Max Angle Angle

Thoracic Left Rotation (30°)

+/-10 % or 5° Rotation Angle:

Max Angle

Thoracic Right Rotation (30°)

+/-10 % or 5° Rotation Angle:

Max Angle

Thoracic Ankylosis in Rotation:

Spine Musculoskeletal Testing Comments

Lower Extremity ROM/MMT

Location R AROM R PROM R MMT L AROM L PROM L MMT Hip Flexion

Hip Extension Hip Adduction Hip Abduction

Hip Internal Rotation Hip External Rotation

Knee Flexion Knee Extension

Ankle Dorsiflexion Ankle Plantarflexion

Ankle Inversion Ankle Eversion

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Upper Extremity ROM/MMT

Location R AROM R PROM R MMT L AROM L PROM L MMT Shoulder Elevation Shoulder Flexion

Shoulder Extension Shoulder Abduction Shoulder Abduction

Horizontal Adduction Horizontal Abduction

External Rotation Internal Rotation Elbow Flexion

Elbow Extension Supination Pronation

Wrist Flexion Wrist Extension Ulnar Deviation Radial Deviation Digit Oposition

Upper Extremity and Lower Extremity Comments

Upper Extremity Testing

Orthotics/Assistive Devices

Devices:

None

Neoprene Lumbar Corset

Ankle Brace

Knee Brace

Shoe/Sole Inserts

Straight Cane

Quad Cane

Walker

Reacher

AFO

Comments:

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Circumferential or Volumetric Measurements

What type of measurement is utilized?

Anatomical

Position

Right Pre

Measurement

Right Post

Measurement

Left Pre

Measurement

Left Post

Measurement

Circumferential/Volumetric Measurement Comments:

Two Point Discrimination

Sharp Dull Awareness

Two Point/Sharp Dull Comments

Musculoskeletal Testing

Semmes Weinstein Monofilament Testing

Lower Extremity Sensation

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Reliability of Pain Waddell Signs

Superficial Tenderness: Positive Negative

Simulation Test: Positive Negative

Distraction: Positive Negative

Regional Disturbances: Positive Negative

Overreaction to Test: Positive Negative

Comments:

Psychometric Testing

McGill Pain Questionnaire: Reliable Unreliable

Ransford Pain Drawing: Reliable Unreliable

Oswestry Low Back: Reliable Unreliable

Oswestry Neck: Reliable Unreliable

Comments:

Upper Extremity Testing

Grip Testing

Does this client present with musculoskeletal based distal upper extremity weakness secondary to a diagnosis

that has caused this distal upper extremity weakness? Right? Yes No Left? Yes No

Grip Strength Group Strength Coefficients of Variation Norms

R L R L R L

Trial 1 CoV(%) Mean

Trial 2 *A coefficient of variation greater than Range

Trial 3 15% denotes an inconsistent test.

Five Span Grip

Position 1 Position 2 Position 3 Position 4 Position 5

Right

Left

Rapid Exchange Grip Strength Test R L

Max Poundage Noted in Tests 5-8

Post Grip Testing Diagnostics

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Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Can tolerate simple grasping within the following frequency:

N/A Avoid Occasional Frequent Continuous

Can tolerate firm grasping within the following frequency:

N/A Avoid Occasional Frequent Continuous

Grip Comments:

Pinch Testing

Key Pinch Key Pinch Coefficients of Variation Key Pinch Norms

R L R L R L

Trial 1 CV (%) Mean

Trial 2 *A coefficient of variation greater than Range

Trail 3 15% is an inconsistent test.

Palmar Pinch Palmar Pinch Coefficients of Variation Palmar Pinch Norms

R L R L R L

Trial 1 CV (%) Mean

Trial 2 *A coefficient of variation greater than Range

Trial 3 15% is an inconsistent test.

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Tip Pinch Tip Pinch Coefficients of Variation Tip Pinch Norms

R L R L R L

Trial 1 CV (%) Mean

Trial 2 *A coefficient of variation greater than Range

Trial 3 15% is an inconsistent test.

Post Pinch Testing Diagnostics

Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate pinching within the following frequency:

N/A Avoid Occasional Frequent Continuous

Pinch Comments:

Fine Motor Coordination

Purdue Pegboard

Right Hand Performed (30 sec): Left Hand Performed (30 sec):

Both Hands Performed (30 sec): Assembly Performed (60 sec):

Moberg’s Pick up Test

Eyes Open (10 – 14 sec)

Trial 1 Right Hand: sec Trial 2 Right Hand: sec

Trial 1 Left Hand: sec Trial 2 Left Hand: sec

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Eyes Closed (within 2 sec)

Trial 1 Right Hand: sec Trial 2 Right Hand: sec

Trial 1 Left Hand: sec Trial 2 Left Hand: sec

Post Fine Motor Testing Diagnostics

Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate fine motor within the following frequency:

N/A Avoid Occasional Frequent Continuous

Fine Motor Comments:

Gross Motor Coordination

Gross Motor Coordination

Box and Block Right Left Post Gross Motor Diagnostics

Right Hand Count Mean Pain Rating 1 2 3 4 5 6 7 8 9 10

Left Hand Count Range Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

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Client can tolerate Gross Motor Coordination within the following frequency?

N/A Avoid Occasional Frequent Continuous

Non-Material Handling

Fast-Paced Walking Post Fast-Paced Walking Diagnostics

Assistive Device? No Yes Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Stride? Even Uneven

Splinting? No Yes

Holding? No Yes

Gait? Non-Antalgic Gait Right Antalgic Gait Left Antalgic Gait

100 Yard Walking Abilities? seconds

Prolonged Walking Post Prolonged Walking Diagnostics

Assistive Device? No Yes Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Stride? Even Uneven

Splinting? No Yes

Holding? No Yes

Gait? Non-Antalgic Gait Right Antalgic Gait Left Antalgic Gait

100 Yard Walking Abilities? seconds

Self Reported Walking Abilities minutes

Prolonged Walking Abilities minutes

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

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Client can tolerate walking within the following frequency:

N/A Avoid Occasional Frequent Continuous

Fast Paced Walking Comments

Prolonged Walking Comments

Forward Reaching Post Reach x1 Diagnostics

Reaching x1 Pain Rating 0 1 2 3 4 5 6 7 8 9 10

History of neck/shoulder injuries? No Yes Heart Rate bpm

Percent of full forward reach ____

Speed? Slow Average Fast

Scapulohumeral Rhythm Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Crepitus? No Palpable Audible Painful

Reaching x10 Post Reach x10 Diagnostics

Percent of full forward reach _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed Slow Average Fast Heart Rate bpm

Scapulohumeral Rhythm Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Crepitus? No Palpable Audible Painful

Reaching x10 Fast Post Reach x10 Fast Diagnostics

Percent of full forward reach _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed Slow Average Fast Heart Rate bpm

Scapulohumeral Rhythm Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Crepitus? No Palpable Audible Painful

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

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Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate forward reaching within the following frequency:

N/A Avoid Occasional Frequent Continuous

Forward Reaching Comments

Above Shoulder Reaching Post Reach x1 Diagnostics

Reaching x1 Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Percent of full above shoulder reach _____ Heart Rate bpm

Speed? Slow Average Fast

Scapulohumeral Rhythm Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Crepitus? No Palpable Audible Painful

Reaching x10 Post Reach x10 Diagnostics

Percent of full above shoulder reach _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Scapulohumeral Rhythm Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Crepitus? No Palpable Audible Painful

Reaching x10 Fast Post Reach x10 Fast Diagnostics

Percent of full above shoulder reach _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Scapulohumeral Rhythm Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Crepitus? No Palpable Audible Painful

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Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate above shoulder reaching within the following frequency:

N/A Avoid Occasional Frequent Continuous

Above Shoulder Reaching Comments

Bending Post Bend x1 Diagnostics

Bend x1 Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Percent of full forward bend _____ Heart Rate bpm

Speed? Slow Average Fast

Movement Pattern? Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Hamstring Tightness? No Deficits Right Left Bilateral

Bend x10 Post Bend x10 Diagnostics

Percent of full forward bend _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Movement Pattern? Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Hamstring Tightness? No Deficits Right Left Bilateral

Bending x10 Fast Post Bend x10 Fast Diagnostics

Percent of full forward bend _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Movement Pattern? Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Hamstring Tightness? No Deficits Right Left Bilateral

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Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate bending within the following frequency:

N/A Avoid Occasional Frequent Continuous

Bending Comments

Squatting Post Squat x1 Diagnostics

Squatting x1 Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Percent of full squat _____ Heart Rate bpm

Speed? Slow Average Fast

Movement Pattern? Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Equal Weight Bearing? No Yes

Crepitus? No Palpable Audible Painful

Squatting x10 Post Squat x10 Diagnostics

Percent of full squat _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Movement Pattern? Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Equal Weight Bearing? No Yes

Crepitus? No Palpable Audible Painful

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

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Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate Squatting within the following frequency:

N/A Avoid Occasional Frequent Continuous

Squatting Comments

Sustained Squatting

This test is best administered in a job simulation fashion

Description of job simulated sustained squatting

Sustained Squatting minutes requested?_____ Post Sust. Squat Diagnostics

Sustained Squatting minutes achieved? _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Heart Rate bpm

Movement Pattern? Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Equal Weight Bearing? No Yes

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

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Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Can tolerate Sustained Squatting within the following frequency?

N/A Avoid Occasional Frequent Continuous

Sustained Kneeling Post Sustained Kneel Diagnostics

Time Tolerated: min Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Movement Pattern? Normal Abnormal Heart Rate bpm

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Equal Weight Bearing? No Yes

Requires Upper Extremity Assistance? No Yes

Crepitus? No Palpable Audible Painful

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Can tolerate sustained kneeling within the following frequency:

N/A Avoid Occasional Frequent Continuous

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Repetitive Kneeling

Kneeling x10 Post Kneel x10 Diagnostics

Percent of full kneel _____ Pain Rating 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Movement Pattern? Normal Abnormal

Pain Correlates with Diagnosis? No Yes

Compensatory Technique? No Yes

Equal Weight Bearing? No Yes

Requires Upper Extremity Assistance? No Yes

Crepitus? No Palpable Audible Painful

Can tolerate repetitive kneel within the following frequency?

N/A Avoid Occasional Frequent Continuous

Kneeling comments

Crawling

Can client tolerate 1-20 minutes of crawling? Yes / No Post Crawling Diagnostics

Can client tolerate 21-40 minutes of crawling? Yes / No Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Can client tolerate 41-60 minutes of crawling? Yes / No Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate crawling within the following frequency:

N/A Avoid Occasional Frequent Continuous

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Crawling Comments:

Static Balance

Romberg Test? sec Post Static Balance Diagnostics

Sharpened Romberg? sec Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Functional Reach? inches Heart Rate bpm

Single leg stance right lower extremity sec

Single leg stance left lower extremity sec

Single leg stance eyes closed right lower extremity sec

Single leg stance eyes closed left lower extremity sec

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate static balance within the following frequency?

N/A Avoid Occasional Frequent Continuous

Dynamic Balance

Gait Level Surface Pass Fail Post Dynamic Balance Diagnostics

Change in gait speed Pass Fail Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Gait with horizontal head turns Pass Fail Heart Rate bpm

Gait with vertical head turns Pass Fail

Gait with pivot turn Pass Fail

Step over obstacle Pass Fail

Gait with narrow base of support Pass Fail

Gait with eyes closed Pass Fail

Ambulating Backward Pass Fail

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Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Can tolerate dynamic balance within the following frequency?

N/A Avoid Occasional Frequent Continuous

Balance Comments

Occasional Material Handling

Pre-Diagnostics

Include text about the importance of the pre-handling diagnostics, their meaning and what is expected of the

clinician during this portion of the assessment, etc., etc., etc.

Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Heart Rate bpm

Job Specific/Bending

Weights Handled Post Job Specific Lift Diagnostics

Peak Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight lbs Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

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Squat Lift

Weights Handled Post Squat Lift Diagnostics

Peak Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight lbs Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Power Lift Weights Handled Post Power Lift Diagnostics

Peak Weight lbs Lift Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight lbs Lift Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Shoulder Lift

Weights Handled Post Shoulder Lift Diagnostics

Peak Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight lbs Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

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Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Overhead Lift

Weights Handled Post Overhead Lift Diagnostics

Peak Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight lbs Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Two Handed Lifting Comments

Client’s overall lifting body mechanics

Two Handed Lifting Comments

Unilateral Lift

Weights Handled Post Unilateral Lift Diagnostics

Peak Weight lbs Pain Rating 1 2 3 4 5 6 7 8 9 10

Occasional Weight lbs Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

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Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Unilateral Lifting Comments

Bilateral Carry

Weights Handled Post Bilateral Carry Diagnostics

Peak Weight lbs Bilateral Carry Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight lbs Bilateral Carry Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Bilateral Carry Comments

Unilateral Carry

Weights Handled Post Unilateral Carry Diagnostics

Peak Weight lbs Unilateral Carry Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight lbs Unilateral Carry Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

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Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Unilateral Carry Comments

Pushing and Pulling

Pushing Weights Handled Post Pushing Diagnostics

Peak Weight HFP Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight HFP Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Pulling Weights Handled Post Pulling Diagnostics

Peak Weight HFP Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Occasional Weight HFP Heart Rate bpm

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

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Pushing and Pulling Comments

Job Simulated Functional Abilities Task 1

Title of Job Sim. Performed:

Description of Job Simulated Activity:

Post Task Diagnostics

Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Heart Rate bpm

Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate Task 1 within the following frequency:

N/A Avoid Occasional Frequent Continuous

Client’s ability to perform job simulated activity:

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Task 2

Title of Job Sim. Performed:

Description of Job Simulated Activity:

Post Task Diagnostics

Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Heart Rate bpm

Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate Task 1 within the following frequency:

N/A Avoid Occasional Frequent Continuous

Client’s ability to perform job simulated activity:

Frequent Material Handling Squat Lift

Pre Handling Diagnostics

Heart Rate bpm

Weights Handled Post Squat Lift Diagnostics

Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Frequent Weight lbs Heart Rate bpm

Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

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Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Power Lift

Pre Handling Diagnostics

Heart Rate bpm

Weights Handled Post Power Lift Diagnostics

Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Frequent Weight lbs Heart Rate bpm

Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Shoulder Lift

Pre Handling Diagnostics

Heart Rate bpm

Weights Handled Post Shoulder lift Diagnostics

Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Frequent Weight lbs Heart Rate bpm

Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

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Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Overhead Lift

Pre Handling Diagnostics

Heart Rate bpm

Weights Handled Post Overhead Lift Diagnostics

Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Frequent Weight lbs Heart Rate bpm

Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Bilateral Carrying

Pre Handling Diagnostics

Heart Rate bpm

Weights Handled Post Bilateral Carry Diagnostics

Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Frequent Weight lbs Heart Rate bpm

Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

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Unilateral Lift

Pre Handling Diagnostics

Heart Rate bpm

Weights Handled Post Unilateral Lift Diagnostics

Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Frequent Weight lbs Heart Rate bpm

Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Unilateral Carry

Pre Handling Diagnostics

Heart Rate bpm

Weights Handled Post Unilateral Carry Diagnostics

Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Frequent Weight lbs Heart Rate bpm

Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

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Push/Pull

Pre Handling Diagnostics

Heart Rate bpm

Weights Handled Post Push and Pull Diagnostics

Push Peak Freq. Wt. horz force lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Push Freq. Wt. horz force lbs Heart Rate bpm

Pull Peak Freq. Wt. horz force lbs Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Pull Freq Wt. horz force lbs

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Comments

Clients overall lifting body mechanics

Frequent Lifting Comments:

Sit/Stand/Climb

Stair Climbing

Pre Stairs Diagnostics: Heart Rate bpm

36 Steps Completed (Occasional) Post 36 steps Diagnostics

Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Reciprocal foot over foot gait? No Yes

Compensatory Techniques? No Yes

Upper Extremity Assistance? No Mild Moderate Significant

Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait

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72 Steps Completed (Frequent) Post 72 steps Diagnostics

Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Reciprocal foot over foot gait? No Yes

Compensatory Techniques? No Yes

Upper Extremity Assistance? No Mild Moderate Significant

Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait

108 Steps Completed (Constant) Post 108 steps Diagnostics

Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Reciprocal foot over foot gait? No Yes

Compensatory Techniques? No Yes

Upper Extremity Assistance? No Mild Moderate Significant

Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate stair climbing within the following frequency:

N/A Avoid Occasional Frequent Continuous

Stair Climbing Comments

Ladder Climbing

Pre Ladder Climbing Diagnostics: Heart Rate bpm

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20 Ladder Rungs Completed (Occasional) Post 20 Ladder Diagnostics

Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Reciprocal foot over foot gait? No Yes

Compensatory Techniques? No Yes

Upper Extremity Assistance? No Mild Moderate Significant

Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait

60 Ladder Rungs Completed (Frequent) Post 60 Ladder Rungs Diagnostics

Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Reciprocal foot over foot gait? No Yes

Compensatory Techniques? No Yes

Upper Extremity Assistance? No Mild Moderate Significant

Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait

100 Ladder Rungs Completed (Constant) Post 100 Ladder Rungs Diagnostics

Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Speed? Slow Average Fast Heart Rate bpm

Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Reciprocal foot over foot gait? No Yes

Compensatory Techniques? No Yes

Upper Extremity Assistance? No Mild Moderate Significant

Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait

Limiting Factors

N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength

Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture

Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment

Pain sign/Symptoms

Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)

Client exhibited an increase in heart rate? Yes No

Client exhibited a true pain behavior? Yes No

Client exhibited an associated mechanical change/deficit? Yes No

Client can tolerate ladder climbing within the following frequencies:

N/A Avoid Occasional Frequent Continuous

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Ladder Climbing Comments

Total Sitting

Within the last week, in a 24 hour period how many hours are you in a lying down position?

How many hours were you sitting prior to coming to this evaluation?

How many hours did it take you to drive to this evaluation?

How many hours do you anticipate being in a sitting position after this evaluation?

How many hours total did the client sit during this evaluation?

How many hours total could you sit during the course of the day?

At One Tim Sitting

What is the longest the client sat at one time during this evaluation?

How many hours at once could you tolerate sitting before needing to change positions?

How many hours are left in the 24 hour day? add up the red questions

Total Standing

How many hours were you in a standing position prior to coming to this evaluation?

How many hours total did the client stand during this evaluation?

How many hours do you anticipate being in a standing position after this evaluation?

How many hours total could you stand during the course of a day?

At One Time Standing

What was the longest this client stood during this evaluation?

How many hours at once could you tolerate standing before needing to change positions?

Red plus Green should equal 22 or more hours to capture a 24 hour day

Post Sit/Stand Diagnostics

Pain Rating 0 1 2 3 4 5 6 7 8 9 10

Heart Rate bpm

Sitting and Standing Comments

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Results & Recommendations

Evaluations Results/Summary

Recommendations