section name header

Notes

History Pain (chronic or acute), stiffness, weakness, trauma, fractures, dislocations, deformities, limitations, immunizations (e.g., tetanus, polio).
Medications Pain medications including prescribed narcotics, anti-inflammatory drugs, and OTC medications.
Mobility
  • Gait, balance, coordination, limitations.
Spine
  • Posture, spinal curvature.
  • Spinal deformities (scoliosis, kyphosis, lordosis).
Extremities
  • Limb length discrepancy.
  • Grip strength.
  • Push-pull strength of feet.

Muscle Strength Grading Scale

  • 0.............. No muscle movement
  • 1...............Visible muscle movement, but no joint movement
  • 2..............Joint movement, but not against gravity
  • 3...............Movement against gravity, but not against resistance
  • 4...............Movement against resistance, but less than normal
  • 5..............Normal strength
Range of Motion
  • Limitations and pain during movement of neck, shoulders, elbows, wrists, spine, hips, knees, and ankles.
  • Tests include: Flexion, extension, rotation, lateral bend, abduction, adduction, circumduction, supination, pronation, inversion, and eversion as applicable.