1
Dr. Date:______Pt.______
Muscle Grading Scale
5 = (normal) complete range of motion against gravity and full resistance for 5 seconds
4 = (good) complete range of motion against gravity with some resistance
3 = (fair) complete range of motion against gravity
2 = (poor) complete range of motion with gravity eliminated
1 = (trace) slight muscle contraction, no joint motion
0 = (zero) no evidence of contraction
(Correlative Neuroanatomy & Functional Neurology, 19th ea.. Chusid)
Wexler Deep Tendon Reflex Grading Scale
(NOTE: 0 - 3 may be normal if equal bilateral. Consider the complete clinical picture)
0 = no response with Jendrassik maneuver
1 = hyporeflexia, present but diminished
2 = normal
3 = hyperreflexia (with no clonus)
4 = hyperreflexia with transient clonus
5 = hyperreflexia with sustained clonus
SINUS EXAMINATION
Inspection : ______
Palpation : ______
Transillumination : (Frontal, Maxillary)______
Comments: ______
CERVICAL RANGE OF MOTION
AROM PROM Flexion(70°)
Flexion(70°) [ ]
LLF(45°) RLF(45°) LLF(45°) RLF(45°)
[ ] [ ]
Left Right Left Right
Rotation Rotation Rotation Rotation
(90°) (90°) (90°) (90°)
[ ] [ ]
Extension(50`) Extension(50`)
[ ]
Comments: ______
THORACOLUMBAR SPINE RANGES OF MOTION
AROM PROM Flexion(90°)
Flexion(90°) [ ]
LLF(30°) RLF(30°) LLF(30°) RLF(30°)
[ ] [ ]
Left Right Left Right
Rotation Rotation Rotation Rotation
(35°) (35°) (35°) (35°)
[ ] [ ]
Extension(50°) Extension(50`)
[ ]
Comments: ______
Dr. Date:______Pt.______
UPPER EXTREMITY RANGES OF MOTION
Apley's Scratch Test ENDFEELS Difference between R & L reaches
Behind the Back: R ______L______cm Restricted ___R ___L
Behind the Head: R ______L______cm Restricted ___R ___L
Across Opposite Shoulder: R ______L______cm Restricted ___R ___L
Comments: ______
Active R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel
Unilateral Elevation (Sagittal) (180°) ______Unilateral Elevation (Coronal) (180°) ______
Bilateral Elevation (Sagital) (180°) ______
Bilateral Elevation (Coronal) (180°) ______
Extension (45°) ______
Adduction (45°) ______
Lateral Rotation (8090°) ______
Medial Rotation (100110°) ______
Active R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel
Elbow Flexion( 135°) ______
Elbow Extension (0°) ______
Forearm Pronation (90°) ______
Forearm Supination (90°) ______
Wrist Flexion(90°) ______
Wrist Extension(70°) ______
Wrist Ulnar Deviation (30°) ______
Wrist Radial Deviation (20°) ______
Hand MCP Flexion (90°) ______
Hand PIP Flexion ( 100°) ______
Hand DIP Flexion (90°) ______
Hand MCP Extension (30°-45° ) ______
Hand PIP Extension (0°) ______
Hand DIP Extension (0-10°) ______
Hand Adduction (20°) ______
Hand Abduction (20°) ______
Thumb Flexion (50°) ______
Thumb Extension (0°) ______
Thumb Abduction (70°) ______
Thumb Adduction (0°) ______
Cornrnents.______
LOWER EXTREMITY RANGES OF MOTION
Active Clearance: Able to do: YES____ No____Keep heels on floor: Yes____ No____
Trendelenberg: Left_____ Right_____ Patrick FABERE: Left_____ Right_____
Active R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel
Hip Flexion( 120°) ______
Hip Abduction(45°) ______
Hip Adduction(20°) ______
Hip Extension(30°) ______
Hip Internal Rot. (35°) ______
Hip External Rot. (45°) ______
KNEE R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel
Flexion ______
Extension ______
Internal Rot. (10°) ______
External Rot. (10°) ______
Dr. Date:______Pt.______
ANKLE R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel
Dorsiflexion(20°) ______
Plantarflexion(50°) ______
Inversion( 15-20°) ______
Eversion '(10°) ______
FOOT/TOES
/MTP R.O.M. Left Right Passive R.O.M. Left Endfeel Right Endfeel
Flexion of Toes ______
Extension of Toes ______
Abduction of Toe ______
Adduction of Toe ______
Comments: ______