Patient Name
Physician
Therapist
Eval Date
DOB
Next MD visit
PERSONAL DATA:
PT History of Pain/Symptoms
1.
Pain Level
Current pain ____/10
Worst pain _____/10
Best pain _____/10
2.
o Pain Type
o Aching
o Dull
o Tingling
o Stabbing
o Burning
o Nauseating
Other:
3.Pain Location
4.What relieves pain?
(positions, movements meds, modalities)
5.What makes pain?
(positions, movements, activities)
6.Pain/Sx’s. Frequency:
o Intermittent
o Constant
7.Duration of Pain
< 16 days
> 16 days
8.Pain
o In Morning
o At Night
9.Symptoms below the knee?
YES
NO
IF YES

PERFORM LOWER QUARTER SCREEN
IF NO

PERFORM SI/PELVIC ASSESSMENT
LOWER QUARTER SCREEN
SI/PELVIC ASSESSMENT
Initial SI Test
SI Re
Test
1.
PSIS Levels in
Sitting:
+
Erhardt Manip performed
1.
PSIS Levels in Sitting:
+
2.
Standing Forward Flexion:
+
YES NO
2.
Standing Forward Flexion:
+
3.
Supine to Sit:
+
Pubic Manip performed
?
3.
Supine to Sit:
+
4.
Prone Knee Flexion:
+
YES NO
4.
Prone Knee Flexion:
+
Total positive:
Audible pop?
YES NO
Total positive:
If 3 / 4
/4
/4
positive
Perform Erhardt & Pubic Manip
Re
Test 4 SI Tests
Document results and proceed to
Lumbar Assessment
Muscle Testing
Sensory Testing
(Intact / Dim
inished /
Absent)
Special Tests
Right
Left
Right
Left
Right
Left
L1/L2
(Hip flex)
Patellar DTR
(L3
4)
(Hypo 1+, Normal 2+, Hyper 3+, Clonus 4+)
L3/L4
(Quads)
Achilles DTR
(S1
2)
(Hypo 1+, Normal 2+, Hyper 3+, Clonus 4+)
L4/L5
(Ant Tib)
Babinski
(+ or
)
L5
(EHL)
Clonus
(If +, # of beats)
L5/S1
(Evertors)
SLR
(+ or
)
for recreation of
“their”
pain/sx’s
S1/S2
(PF’ers)