Beruflich Dokumente
Kultur Dokumente
Examination
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Patient Name:
Chief Complaint:
History of problem:
Nature of discomfort/pain
Location (anatomic)
Duration
Onset
Course
Aggravating and/or alleviating factors
Treatments and response
Left
Stance Evaluation:
Angle of gait:
Base of gait:
Foot appearance
Tibial influence
Relaxed calcaneal stance position (RCSP)
Neutral calcaneal stance position (NCSP)
Non-Weight Bearing Evaluation:
Limb length:
Hip sagittal planeKnee extended
Knee flexed
Hip transverse planeKnee extended
Knee flexed
Hip frontal plane
Knee sagittal plane
Knee recurvatum
Ankle sagittal planeKnee extended
Knee flexed
Subtalar jointInversion
Eversion
Right
Normative values:
0
Dorsal & plantar excursion 5mm
Dorsal 65 or >unloaded/20-40 loaded
5/5:
5/5:
5/5:
5/5:
normal
normal
normal
normal
strength
strength
strength
strength
Balance intact
2+ normal
2+ normal
No hallux extension
Absent
Present
Signature of resident
Abducted
Apropulsive
Adducted
Ataxic
Charcot
Circumduction
Equinovarus Other (See column A )
High arch
Propulsive
Low arch
Scissor
Normal arch Shuffling
Other (See col Steppage
Rectus
Trendelenberg
Waddling
Balance intact
Balance not intact
Other (See column A )
Absent
Present
Medial
Central
Lateral
Hallux extension
Present
No Hallux extension
Accomodative
Ankle foot orthosis (AFO)
Arizona brace
Bilaminate
Charcot restraint walker (CROW)
Functional
Leather
Other (enter in column A )
Plastizote
Trilaminate
0 Absent
1+ Diminished
2+ "Normal"
3+ Hyperactive without clonus
0/5: no contraction
1/5: muscle flicker, but no movement
2/5: movement possible, but not against gravity (testing in the horizontal plane)
3/5: movement possible against gravity, but not against resistance by the examiner
4/5: movement possible against some resistance by the examiner
5/5: normal strength