Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

1

Date: _________________ Exam Type: Initial/1/2/3/4/5/6/7 Re-exam/ Final

Focus exam/ Expanded exam/ Detail exam

Height:_______ Wgt:_________ Sex: M/F

Development: Good/ Fair/ poor BMI: Good/ Fair/ Poor

Fracture screen injured area: ( ) tuning fork ( ) percussion ( ) torsion ( ) 5 step ( ) WNL

Temp: Oral___________ Axillary:___________

BP: ___________ Respiration(RPM/rhythm/depth/effort):_______________

History Birth control Y or N Blurred vision Y or N AIDS Y or N

Hypertension Y or N Tinnitis Y or N Vertigo Y or N Atherosclerosis Y or N Speech changes Y or N Loss of consciousness Y or N Hx of CVA Y or N Swallowing issue Y or N Collapse W/O LOC Y or N Anticoagulants Y or N HIV Y or N Smoking Y or N Alcohol Y or N Illegal drug use Y or N Urinary or Bowel issues Y or N _______________________________________________________________

_______________________________________________________________

General Inspection: Comments: ( ) WNL or explanation

_______________________________________________________________

_______________________________________________________________

Posture assessment:

Observation Findings: √ if WNL

Observation Detail Observation Detail

Head tilt Finger Flexed

Head rotation Fingers Ext.

Cervical Curve Boutonnierre def.

C7-T1 Junction Swan neck def.

Shoulder level? Mallet finger

Scapula winging Heberden node

Round shoulders Bouchard nodes

Scap. Rot. Med Antalgia

Scap. Rot. Lat Kyphosis Curve

Humerus Int. Rot. Lordosis Curve

Humerus Ext. Rot Scoliotic curve

GH Sulcus Sign hyper/Hypo/Norm

AC Step Defect Squat rise

Elbow flexed Toe Raises

Elbow Hyperext. Heel walk

Valgus forearm Gait

Varus Forearm Leg length

Forearm Pronate Genu Varum

Forearm supin. Genu Valgum

Hand/finger deform. Iliac Crest Height

Bruising Toe in/ Toe out

Knee hyperextended Foot arch right

Shoe wear signs Foot arch left

Achilles angle Patellar position

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

Date: _________________ Exam Type: Initial/1/2/3/4/5/6/7 Re-exam/ Final

Focus exam/ Expanded exam/ Detail exam

Height:_______ Wgt:_________ Sex: M/F

Development: Good/ Fair/ poor BMI: Good/ Fair/ Poor

Fracture screen injured area: ( ) tuning fork ( ) percussion ( ) torsion ( ) 5 step ( ) WNL

Temp: Oral___________ Axillary:___________

BP: ___________ Respiration(RPM/rhythm/depth/effort):_______________

History Birth control Y or N Blurred vision Y or N AIDS Y or N

Hypertension Y or N Tinnitis Y or N Vertigo Y or N Atherosclerosis Y or N Speech changes Y or N Loss of consciousness Y or N Hx of CVA Y or N Swallowing issue Y or N Collapse W/O LOC Y or N Anticoagulants Y or N HIV Y or N Smoking Y or N Alcohol Y or N Illegal drug use Y or N Urinary or Bowel issues Y or N _______________________________________________________________

_______________________________________________________________

General Inspection: Comments: ( ) WNL or explanation

_______________________________________________________________

_______________________________________________________________

Posture assessment:

Observation Findings: √ if WNL

Observation Detail Observation Detail

Head tilt Finger Flexed

Head rotation Fingers Ext.

Cervical Curve Boutonnierre def.

C7-T1 Junction Swan neck def.

Shoulder level? Mallet finger

Scapula winging Heberden node

Round shoulders Bouchard nodes

Scap. Rot. Med Antalgia

Scap. Rot. Lat Kyphosis Curve

Humerus Int. Rot. Lordosis Curve

Humerus Ext. Rot Scoliotic curve

GH Sulcus Sign hyper/Hypo/Norm

AC Step Defect Squat rise

Elbow flexed Toe Raises

Elbow Hyperext. Heel walk

Valgus forearm Gait

Varus Forearm Leg length

Forearm Pronate Genu Varum

Forearm supin. Genu Valgum

Hand/finger deform. Iliac Crest Height

Bruising Toe in/ Toe out

Knee hyperextended Foot arch right

Shoe wear signs Foot arch left

Achilles angle Patellar position

_____________________________________________

_____________________________________________

_____________________________________________

_____________________________________________

Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

2

Date:____________

Palpation assessment: WNL (--)

Pain (circle) spasm (s) Edema (e) Fibrotic(F) TP(X) ache (A) Burn(B) Tingle (T) Cervical skin Biceps tendon Gluteus medius

Lymph nodes Head of Radius Quadriceps

Temporalis m. Radial Tunnel Gastroc-Soleus

Masseter Lat. Epidicondyle Hip Joint Capsule

TMJ Lat. Coll. Ligament Iliopsoas

Scalenes Lat. Supracondylar rdg Adductor mucles

SCM Common Extensor Tdn Adductor Canal

Levator Scapulae Anconeus Pes Anserine

Pec. Major Brachioradialis Medial joint/ meniscus

Rhomboids Ext Carpi Ulnaris Med Femoral Condyle

Suboccipitals Ext Carpi Radialis long Medial Collateral Lig

Pos. cerv. Musc. Ext Carpi Radialis Brev Popliteal Fossa

Trachea Mobility Extensor Digitorum Gastroc. Heads

Thyroid Supinator Lat. Collateral Lig

Clavicle SC JT Olecranon Lateral joint/ meniscus

Clavicle AC JT Olecranon Bursa Lat. Femoral Condyle

Thoracic Outlet Cubital Fossa Lat. Tibial Condyle

Trap. Medial Brachialis Medial Maleoli

Trap Lower Thumb extensors Lateral malleoli

Trap lateral Interossei Navicular

Thoracic spine Thenar pad Cuboid

Supraspinatus HypoThenar pad Cuneiforms

Infraspinatus Carpal tunnel Talus (head, neck , trochlea)

Teres Minor Tunnel of Guyon Phalanges and joints

Teres Major Anat snuff box Sinus Tarsi

Rot. Cuff Post. Carpals Ant. Talofibular lig

Rot Cuff Sup. Metacarpals Calcaneofibular lig

Rot Cuff. Ant Fingers/joints Post talofibular lig

Lat. Dorsi Thumb/joints Spring ligament

Subscapularis Trapezoid Deltoid ligament

Medial Ribs Pisiform Peroneal muscles

Lateral ribs Ulnar/ radial Styloids Peroneal ligaments

Coracoid Process Abdomen Tibialis anterior

Pec. Minor Pubic syphisis Achilles Tendon

Pec major Lumbar Paraspinals Tarsal Tunnel

Deltiod Iliac Crest Tibia (Heads and joints)

Triceps Quadratus Lumborum Fibula (heads and joints)

Coracobrachialis PSIS Calcaneal Bursa

Biceps Brachii ASIS Plantar Fascia

Bicipital Groove Ischial Tuberosities Plantar Muscles

Medial Condyle Hamstrings Heel Spur

Ulnar Groove TFL/ ITD Abdominal Artery

Med. Coll. Lig. Greater Trochanter Liver/ Gallbladder

Common flex tend. Piriformis Large Intestine

Flexor Carpi Ulnaris Sacrotuberous Ligs. Maxillary sinus

Palmaris Longus SI Joint Frontal Sinus

Flex Carpi Radialis Sacrospinous Ligs.

Pronator teres Gluteous maximus

SEG FINDINGS SEG FINDINGS

C0 T6

C1 T7

C2 T8

C3 T9

C4 T10

C5 T11

C6 T12

C7 L1

T1 L2

T2 L3

T3 L4

T4 L5

T5 SAC

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Date:____________

Palpation assessment: WNL (--) Pain (circle) spasm (s) Edema (e) Fibrotic(F) TP(X) ache (A) Burn(B) Tingle (T) Cervical skin Biceps tendon Gluteus medius

Lymph nodes Head of Radius Quadriceps

Temporalis m. Radial Tunnel Gastroc-Soleus

Masseter Lat. Epidicondyle Hip Joint Capsule

TMJ Lat. Coll. Ligament Iliopsoas

Scalenes Lat. Supracondylar rdg Adductor mucles

SCM Common Extensor Tdn Adductor Canal

Levator Scapulae Anconeus Pes Anserine

Pec. Major Brachioradialis Medial joint/ meniscus

Rhomboids Ext Carpi Ulnaris Med Femoral Condyle

Suboccipitals Ext Carpi Radialis long Medial Collateral Lig

Pos. cerv. Musc. Ext Carpi Radialis Brev Popliteal Fossa

Trachea Mobility Extensor Digitorum Gastroc. Heads

Thyroid Supinator Lat. Collateral Lig

Clavicle SC JT Olecranon Lateral joint/ meniscus

Clavicle AC JT Olecranon Bursa Lat. Femoral Condyle

Thoracic Outlet Cubital Fossa Lat. Tibial Condyle

Trap. Medial Brachialis Medial Maleoli

Trap Lower Thumb extensors Lateral malleoli

Trap lateral Interossei Navicular

Thoracic spine Thenar pad Cuboid

Supraspinatus HypoThenar pad Cuneiforms

Infraspinatus Carpal tunnel Talus (head, neck , trochlea)

Teres Minor Tunnel of Guyon Phalanges and joints

Teres Major Anat snuff box Sinus Tarsi

Rot. Cuff Post. Carpals Ant. Talofibular lig

Rot Cuff Sup. Metacarpals Calcaneofibular lig

Rot Cuff. Ant Fingers/joints Post talofibular lig

Lat. Dorsi Thumb/joints Spring ligament

Subscapularis Trapezoid Deltoid ligament

Medial Ribs Pisiform Peroneal muscles

Lateral ribs Ulnar/ radial Styloids Peroneal ligaments

Coracoid Process Abdomen Tibialis anterior

Pec. Minor Pubic syphisis Achilles Tendon

Pec major Lumbar Paraspinals Tarsal Tunnel

Deltiod Iliac Crest Tibia (Heads and joints)

Triceps Quadratus Lumborum Fibula (heads and joints)

Coracobrachialis PSIS Calcaneal Bursa

Biceps Brachii ASIS Plantar Fascia

Bicipital Groove Ischial Tuberosities Plantar Muscles

Medial Condyle Hamstrings Heel Spur

Ulnar Groove TFL/ ITD Abdominal Artery

Med. Coll. Lig. Greater Trochanter Liver/ Gallbladder

Common flex tend. Piriformis Large Intestine

Flexor Carpi Ulnaris Sacrotuberous Ligs. Maxillary sinus

Palmaris Longus SI Joint Frontal Sinus

Flex Carpi Radialis Sacrospinous Ligs.

Pronator teres Gluteous maximus

SEG FINDINGS SEG FINDINGS

C0 T6

C1 T7

C2 T8

C3 T9

C4 T10

C5 T11

C6 T12

C7 L1

T1 L2

T2 L3

T3 L4

T4 L5

T5 SAC

_______________________________________________________________

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_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

3

Palpation assessment:

Pain (circle) spasm (s) Edema (e) Fibrotic(F) TP(X) ache (A) Burn(B) Tingle (T)

Palpation assessment:

Palpation assessment:

Pain (circle) spasm (s) Edema (e) Fibrotic(F) TP(X) ache (A) Burn(B) Tingle (T)

Pulses: (Temporal: __ R __L)( Brachial: __R __L)( Radial: __R __L)

(Abdominal: WNL/ Refer) ( Femoral:__R__L)( Dorsal Pedis:__R__L)

____________________________________________

Lymph Nodes: R/L, Cervical (WNL), Axillary (WNL), Inguinal (WNL) or explan.

_______________________________________________________________

Thyroid: Swollen/ Fixed Tissue/ Asymmetrical/Midline/ Masses or Nodules?

_______________________________________________________________

Mouth/ TMJ Exam: Mucosa, TMJ motion, TP of

Mastication Muscles, Mastication issues:_____________

______________________________________________

______________________________________________

Pulses: (Temporal: __ R __L)( Brachial: __R __L)( Radial: __R __L)

(Abdominal: WNL/ Refer) ( Femoral:__R__L)( Dorsal Pedis:__R__L)

____________________________________________

Lymph Nodes: R/L, Cervical (WNL), Axillary (WNL), Inguinal (WNL) or explan.

_______________________________________________________________

Thyroid: Swollen/ Fixed Tissue/ Asymmetrical/Midline/ Masses or Nodules?

_______________________________________________________________

Mouth/ TMJ Exam: Mucosa, TMJ motion, TP of

Mastication Muscles, Mastication issues:_____________

______________________________________________

______________________________________________

Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

4

Date: _________________

Sensory Disturbances

PT Description (subjective S):______________________________________

______________________________________________________________

Clinician objective: Mark Dermatome (X) then describe abnormal finding

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Motor exam ( ) check if WNL Motor (norm 5, good 4, fair 3, poor 2, trace 1, 0) Right Left Pain

Cervical Flexion (C1-C2)

Cervical Extension (C2, C3, XI)

Cervical lateral Flexion (C3)

Cervical Rotation (C1-4, XI)

Shoulder Elevation, Trapezius (CNXI, C3-C6)

Shoulder Abduction Deltoid (C4-C6)

Elbow Flexion Biceps (C5-C6)

Elbow Extension Triceps (C6-C8)

Wrist/ Finger Flexion (C7-T1)

Wrist/ Finger Extension (C6-C8)

Finger Interossei (C8, T1, Ulnar)

Hip Flexion (L1-L3)

Knee Extension (L2-L4)

Knee Flexion (L4-S1)

Plantar Flexion ((L5-S1)

Dorsiflexion (L4-L5)

Hip External Rotators

Foot Eversion

Reflexes ( ) Check if WNL Refexes (0 none, 2 norm, 5 hyper w/sust. clonus) Right Left Pain

Biceps (C5 Musculocutaneous)

Brachioradialis (C6 Radial)

Triceps (C7 Radial)

Patellar (L4 Femoral)

Medial hamstring (L5 Sciatic)

Achilles (S1 Tibial)

Babinski

Other:

TMJ ROM ( ) check if WNL

Deviation: Right or Left Muscle size: Right or Left Larger

Temporal Muscles: Tender/ TP/ Right/ Left

TMJ Joint palpation: Pain/ Clicking/ Popping/ Abnormal Motion

_______________________________________________________________

_______________________________________________________________

Date: _________________

Sensory Disturbances

PT Description (subjective S): ______________________________________

______________________________________________________________

Clinician Objective: Mark Dermatome (X) then describe abnormal finding

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Motor exam ( ) check if WNL Motor (norm 5, good 4, fair 3, poor 2, trace 1, 0) Right Left Pain

Cervical Flexion (C1-C2)

Cervial Extension (C2, C3, XI)

Cervical lateral Flexion (C3)

Cervical Rotation (C1-4, XI)

Shoulder Elevation, Trapezius (CNXI, C3-C6)

Shoulder Abduction Deltoid (C4-C6)

Elbow Flexion Biceps (C5-C6)

Elbow Extension Triceps (C6-C8)

Wrist/ Finger Flexion (C7-T1)

Wrist/ Finger Extension (C6-C8)

Finger Interossei (C8, T1, Ulnar)

Hip Flexion (L1-L3)

Knee Extension (L2-L4)

Knee Flexion (L4-S1)

Plantar Flexion ((L5-S1)

Dorsiflexion (L4-L5)

Hip External Rotators

Foot Eversion

Reflexes ( ) Check if WNL Refexes (0 none, 2 norm, 5 hyper w/sust. clonus) Right Left Pain

Biceps (C5 Musculocutaneous)

Brachioradialis (C6 Radial)

Triceps (C7 Radial)

Patellar (L4 Femoral)

Medial hamstring (L5 Sciatic)

Achilles (S1 Tibial)

Babinski

Other:

TMJ ROM ( ) check if WNL

Deviation: Right or Left Muscle size: Right or Left Larger

Temporal Muscles: Tender/ TP/ Right/ Left

TMJ Joint palpation: Pain/ Clicking/ Popping/ Abnormal Motion

_______________________________________________________________

_______________________________________________________________

Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

5

Date:_____________________

ROM Cervical Spine Active Passive Pain

Left Right Left Right

Flexion (50)

Extension(60)

Lat Flexion (45)

Rotation (80)

Findings: ____________________________________________________________________________________

Shoulder Left Right Left Right Pain

Flexion (180)

Extension (50)

Abduction (180)

Adduction (30)

Internal Rot. (90)

External Rot. (80)

Scapular Rhythm

Findings: ____________________________________________________________________________________

Elbow and Wrist Left Right Left Right Pain

Elbow flex. (150)

Elbow Ext. (0)

Elbow Sup. (90)

Elbow Pron. (90)

Wrist Flex. (80)

Wrist Ext. (70)

Ulnar Dev. (30)

Radial Dev. (20)

Findings: ____________________________________________________________________________________

Lumbosacral Left Right Left Right Pain

Flexion (60)

Extension (25)

Lateral Flex. (25)

Rotation (10)

SI flex/ext. (0-10)

SI Ext/ Int. (5-10)

Lumbosacral rhythm:

Findings:

____________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date:_________________________

ROM Cervical Spine Active Passive Pain

Left Right Left Right

Flexion (50)

Extension(60)

Lat Flexion (45)

Rotation (80)

Findings: ____________________________________________________________________________________

Shoulder Left Right Left Right Pain

Flexion (180)

Extension (50)

Abduction (180)

Adduction (30)

Internal Rot. (90)

External Rot. (80)

Scapular Rhythm

Findings: ____________________________________________________________________________________

Elbow and Wrist Left Right Left Right Pain

Elbow flex. (150)

Elbow Ext. (0)

Elbow Sup. (90)

Elbow Pron. (90)

Wrist Flex. (80)

Wrist Ext. (70)

Ulnar Dev. (30)

Radial Dev. (20)

Findings: ____________________________________________________________________________________

Lumbosacral Left Right Left Right Pain

Flexion (60)

Extension (25)

Lateral Flex. (25)

Rotation (10)

SI flex/ext. (0-10)

SI Ext/ Int. (5-10)

Lumbosacral rhythm:

Findings:

____________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

6

Date:_____________________

ROM Hip Active Passive Pain

Left Right Left Right

Flexion with bent knee (120)

Flexion SLR (90)

Extension (30)

Abduction (50)

Adduction (30)

Int. Rotation (40)

Ext. Rotation (50)

Findings: ____________________________________________________________________________________

Knee Left Right Left Right Pain

Flexion (150)

Extension (0)

Int. Rotation

Ext. Rotation

A-P Tibia /femur

A-P Tibia/ Fibula

Patella joint play

Findings: ____________________________________________________________________________________

Ankle and Foot Left Right Left Right Pain

Plantar Flex.(40)

Dorsiflexion (20)

Inversion (20)

Eversion (10)

Toe Flex.

Toe Ext.

Findings: ____________________________________________________________________________________

Orthopedic/ Neurological Testing

OrthoNero WNL R L Details Cervicothoracic √ +/- +\- Referal, pain, location of symptoms Cervical compress Max Compression Cerv.Distraction Soto Hall Shoulder Depress. Adsons Edens Wrights Roo’s Valsalva Bakody sign Swallowing Test

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VBI Tests- auscultate for bruits

Carotid Yes/ No Subclavian Yes/ No

Hautants Test + / - Kleins Maneuver + / -

Max Rot & Ext 30 sec Right ( + / -) Left (+ / -)

Date:_____________________

ROM Hip Active Passive Pain

Left Right Left Right

Flexion with bent knee (120)

Flexion SLR (90)

Extension (30)

Abduction (50)

Adduction (30)

Int. Rotation (40)

Ext. Rotation (50)

Findings: ____________________________________________________________________________________

Knee Left Right Left Right Pain

Flexion (150)

Extension (0)

Int. Rotation

Ext. Rotation

A-P Tibia /femur

A-P Tibia/ Fibula

Patella joint play

Findings: ____________________________________________________________________________________

Ankle and Foot Left Right Left Right Pain

Plantar Flex.(40)

Dorsiflexion (20)

Inversion (20)

Eversion (10)

Toe Flex.

Toe Ext.

Findings: ____________________________________________________________________________________

Orthopedic/ Neurological Testing

OrthoNero WNL R L Details Cervicothoracic √ +/- +\- Referal, pain, location of symptoms Cervical compress Max Compression Cerv.Distraction Soto Hall Shoulder Depress. Adsons Edens Wrights Roo’s Valsalva Bakody sign Swallowing Test

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

VBI Tests- auscultate for bruits

Carotid Yes/ No Subclavian Yes/ No

Hautants Test + / - Kleins Maneuver + / -

Max Rot & Ext 30 sec Right ( + / -) Left (+ / -)

Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

7

Date:___________________

OrthoNero WNL R L Details Shoulder √ +/- +\- Referal, pain, location of symptoms Screening Apley Superior Apley Inferior Codman Arm Drop Dugas Supraspinatus tst Cross imping. sign Impingement HawkinsKennedy Impingement Sign Painful Arc Passive Neer’s Dawbarns sign Bicep Tendonitis Yergasens Speeds Bicipital Instab. Tst Empty Can Instability Ant. Apprehend. Post. Apprehen. Load & Shift Faigan’s Labral Tear Hyperabduction Clunk test Crank Test Obriens test Pos imping. sign Elbow Test- Instability Valgus stress-straight Valgus stress-30 deg Varus Stress- straight Varus Stress- 30 deg Elbow-Med epicondylitis Reverse Cozens Reverse Mills Reverse book lift Elbow-Lat epiconylitis Book lift test Cozens Mill’s Kaplan’s Elbow neuropathy Tinel’s at elbow Tinel’s at wrist Pronator stretch Dynamometer #1 Right Left

Dynamometer #2 Right Left

Dynamometer #3 Right Left

Wrist Phalens (median nerve) Froment (Ulnar) Scaphoid Fx Bracelet Thumb abd. Stress Thumb grind Finkelsteins Tinels (carpal and Guyon)

Date:_____________________

OrthoNero WNL R L Details Shoulder √ +/- +\- Referal, pain, location of symptoms Screening Apley Superior Apley Inferior Codman Arm Drop Dugas Supraspinatus tst Cross imping. sign Impingement HawkinsKennedy Impingement Sign Painful Arc Passive Neer’s Dawbarns sign Bicep Tendonitis Yergasens Speeds Bicipital Instab. Tst Empty Can Instability Ant. Apprehend. Post. Apprehen. Load & Shift Faigan’s Labral Tear Hyperabduction Clunk test Crank Test Obriens test Pos imping. sign Elbow Test- Instability Valgus stress-straight Valgus stress-30 deg Varus Stress- straight Varus Stress- 30 deg Elbow-Med epicondylitis Reverse Cozens Reverse Mills Reverse book lift Elbow-Lat epiconylitis Book lift test Cozens Mill’s Kaplan’s Elbow neuropathy Tinel’s at elbow Tinel’s at wrist Pronator stretch Dynamometer #1 Right Left

Dynamometer #2 Right Left

Dynamometer #3 Right Left

Wrist Phalens (median nerve) Froment (Ulnar) Scaphoid Fx Bracelet Thumb abd. Stress Thumb grind Finkelsteins Tinels (carpal and Guyon)

Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

8

Date:_______________

Lumbosacral WNL R L Details √ +/- +\- Referal, pain, location of symptoms Adams sign Bechterews SLR Bragards Valsalva Milgrams Goldthwaits Percussion SP Percussion muscles Nachlas/Ely/Hibbs Bowstring sign Burns bench maling. Lasegue Minors sign Iliac compression Gaenslens test Lewin-Gaenslens Hip abd. stress Yeomans Test Patrick Fabere Laguerre Brudzinskis mening. sign Trendelenburg Magnusens maling. Hyperextension Lindners sign Double SLR Adams Position Homans sign thrombosis Mankopfs sign- pulses Thomas Test Leg length Obers Heel walk Toe walk Toe Touch Piriformis Knee Bounce home Ballotment Mcmurrys Ant Drawer Post Drawer Valgus stress (0) Valgus Stress (30) Varus stress (0) Varus stess (30) Patellar apprehen. Patellar grind Apley compression Apley Distraction Hyperflexion test Meniscus medial Meniscus lateral Clarkes test

Date:______________

Lumbosacral WNL R L Details √ +/- +\- Referal, pain, location of symptoms Adams sign Bechterews SLR Bragards Valsalva Milgrams Goldthwaits Percussion SP Percussion muscles Nachlas/Ely/Hibbs Bowstring sign Burns bench maling. Lasegue Minors sign Iliac compression Gaenslens test Lewin-Gaenslens Hip abd. stress Yeomans Test Patrick Fabere Laguerre Brudzinskis mening. sign Trendelenburg Magnusens maling. Hyperextension Lindners sign Double SLR Adams Position Homans sign thrombosis Mankopfs sign- pulses Thomas Test Leg length Obers Heel walk Toe walk Toe Touch Piriformis Knee Bounce home Ballotment Mcmurrys Ant Drawer Post Drawer Valgus stress (0) Valgus Stress (30) Varus stress (0) Varus stess (30) Patellar apprehen. Patellar grind Apley compression Apley Distraction Hyperflexion test Meniscus medial Meniscus lateral Clarkes test

Whitmire Chiropractic [PATIENT EXAM FORM 2/2012]

Patient: John-Paul Whitmire DC Signed:______________________ Signed:______________________

1127Broadway St NE, suite 360, Salem OR 97301 Phone: (503)-363-3483 Fax: (503)-373-3685

9

Date:____________________

Ankle/ Leg WNL R L Details √ +/- +\- Referal, pain, location of symptoms Anterior drawer Posterior drawer Inv. Neutral Inv. Plantar flexed Eversion of foot Rotational stress Hoffas sign Achilles squeeze Calcaneal squeeze (3 way) Homans sign/calf squeeze Mortons ft squeeze Tinels at the ankle

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Initial Review of findings day one: Date:_______________________

Finding #1______________________________________________________

TX Plan: ______________________________________________________

Finding #2______________________________________________________

TX Plan: ______________________________________________________

Finding #3______________________________________________________

TX Plan: ______________________________________________________

Finding #4______________________________________________________

TX Plan: ______________________________________________________

Finding #5______________________________________________________

TX Plan: ______________________________________________________

Finding #6______________________________________________________

TX Plan: ______________________________________________________

Date:_________________

Ankle/ Leg WNL R L Details √ +/- +\- Referal, pain, location of symptoms Anterior drawer Posterior drawer Inv. Neutral Inv. Plantar flexed Eversion of foot Rotational stress Hoffas sign Achilles squeeze Calcaneal squeeze (3 way) Homans sign/calf squeeze Mortons ft squeeze Tinels at the ankle

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Initial Review of findings day one: Date:_______________________

Finding #1______________________________________________________

TX Plan: ______________________________________________________

Finding #2______________________________________________________

TX Plan: ______________________________________________________

Finding #3______________________________________________________

TX Plan: ______________________________________________________

Finding #4______________________________________________________

TX Plan: ______________________________________________________

Finding #5______________________________________________________

TX Plan: ______________________________________________________

Finding #6______________________________________________________

TX Plan: ______________________________________________________