Jenny Jones - Sample EOF Checklist 2015
(Needs H&P and complains of chest pain)
SP
Master Interview Rating Scale revised 2015 (MIRS)
1. Item 1: Opening
() () () () ()
5 4 3 2 1
Notes: The Learner opened by introducing themselves (including their last
name), clarifying their role, and greeting the patient. The greeting
should include good eye contact and a smile.
2. Item 4: Eliciting the Narrative Thread
() () () () ()
5 4 3 2 1
Notes: The Learner encouraged and let the patient talk about the patient's
problem(s). The Learner did not stop the patient or introduce new
information.
3. Item 5: Timeline
() () () () ()
5 4 3 2 1
Notes: The Learner obtained sufficient information so that a chronology of
the chief complaint and history of the present illness can be
established. The chronology of any associated symptoms is also
established.
4. Item 6: Questioning Skills--Types of Questions
() () () () ()
5 4 3 2 1
Notes: The Learner begins information gathering with more than one openended question. This is followed up by more specific or direct
questions. Each major line of questioning is begun with an openended question. No poor question types are used.
5. Item 8: Lack of Jargon
() () () () ()
5 4 3 2 1
Notes: The interviewer asks questions and provides information in language
that is easily understood; content is free of difficult medical terms and
jargon. Words are IMMEDIATELY DEFINED for the patient.
Language is used that is appropriate to the patient's level of
education.
6. Item 13: Verbal Facilitation Skills and Encouragement
() () () () ()
5 4 3 2 1
Notes: The Learner used facilitation skills throughout the interview. Verbal
encouragement, use of short statements, and echoing were used when
appropriate.
7. Item 14: Non-Verbal Facilitation Skills
Notes: The Learner put the patient at ease and facilitated communication by
using good eye contact; relaxed, open body language; and appropriate
() () () () ()
5 4 3 2 1
facial expressions; and by eliminating physical barriers. Physical
contact was made with the patient, as appropriate.
8. Item 16: Encouragement of Questions
() () () () ()
5 4 3 2 1
Notes: The Learner encouraged the patient to ask questions about the topics
discussed. The Learner also gives the patient the opportunity to bring
up additional topics or points not covered in the interview (e.g.,
"We've discussed many things. Are there any questions you might
like to ask concerning your problem?" Is there anything else at all
you'd like to talk about?") This is particularly important at the end of
the interview.
9. Comments:
Exam Etiquette Revised 2015 (EE)
10. Learner is cleansing hands when he/she enters the room or tells you they have
cleaned their hands or washes hands at any point prior to the physical exam
() ()
Yes No
11. Drapes appropriately and protects modesty while examining you appropriately
(not through gown or clothing)
() ()
Yes No
Notes: Lowers gown from above to just above nipple line to inspect and palpate
upper chest. Raises gown from below to just below nipple line to palpate and
auscultate lower chest. For abdomen raises gown and lowers sheet to expose
all of abdomen down to top of pubic hair. For straight leg raising places sheet
between legs before doing straight leg raising.
12. Learner describes physical exam or procedures to you
() ()
Yes No
Notes: Learner should tell patient that he/she is going to do a physical exam. Should
explain in general terms each body system exam (I'm going to examine your
heart now, I'm going to examine your abdomen now, etc.).
13. Learner considers your comfort during exam
() ()
Yes No
Notes: Pulls out foot rest when patient is laying down; avoids unnecessary position
changes, helps or offers to help patient sit/stand up, is not unnecessarily rough
with physical exam.
14. Learner closes visit properly.
Notes: Learner indicates that visit is over gracefully and professionally.
15. Comments:
() ()
Yes No
Patient Satisfaction (PS)
16. Is this a doctor you would ( ) Definitely ( ) Probably ( ) Not
see again in the future?
Yes
Yes
Sure
( ) Probably ( ) Definitely
No
No
17. Comments:
Pre-Encounter Learner
Door Information (Door Info)
Patient Door Chart:
Name: Jenny Jones
Age: Ask Your Patient
Setting: Primary Care Physician's Office
Chief Complaint: Needs an annual physical exam & complaining of chest discomfort
BP 128/72
HR 84 RR 16
T 100.2
Learner Instructions (LII)
Learner Instructions:
You have 45 minutes to:
1.
2.
3.
Elicit a complete (complete) history including chief complaint, history of present
illness, past history, medications, allergies, family history, social history & review of
systems
Perform a complete physical exam which includes examination of each body system
Demonstrate appropriate communication skills, professionalism, and skills that promote
patient comfort and understanding.
You will then have 10 minutes to:
1. Receive feedback from the patient and a faculty member.
Honor Code (HC)
18. It is considered a violation of the honor code to discuss (either by giving or receiving
information) cases, feedback, your performance, the logistics of the exam or anything related to
this exam with others, either before, during or following the exam. Please initial in the box to the
right that you agree to abide by the honor code for this case.
Please select "SUBMIT" at the bottom of this section before you enter the exam room. Please do
NOT close the Learning Space software program.
Faculty Observation and Narrative
History of Present Illness (HPI)
19. Establishes or confirms the chief complaint or reason for the visit.
()
()
Yes No
20. Location of pain
()
()
Yes No
21. Other symptoms associated with the pain:
()
()
Yes No
22. Character of pain.
()
()
Yes No
23. Alleviating factors.
()
()
Yes No
24. Aggravating factors.
()
()
Yes No
25. Timing of pain.
()
()
Yes No
Notes: Including onset, constant or intermittent, getting worse since onset, etc.
26. Environment/context in which pain occurs.
()
()
Yes No
Notes: Setting in which pain occurs (food, time of day, activity etc.)
27. Severity
()
()
Yes No
Notes: For pain quantified on a 10 pt. scale. For other symptoms (fatigue, shortness
of breath, etc. better quantified by a description of how much it interferes
with ADLs (activities of daily living).
28. History of this pain before.
29. Comments:
()
()
Yes No
Past History (PH)
30. Past medical history
()
Yes
( ) No
()
Yes
( ) No
Notes: chronic illnesses, hospitalizations, immunizations
31. Past surgical history
Notes: surgeries, major trauma, fractures
32. Past ob/gyn history
( ) Yes
( ) No ( ) Not Applicable
(males)
Notes: pregnancies, live births,
33. Prescription Medications
()
Yes
( ) No
34. OTC medications
()
Yes
( ) No
35. Medication allergies
()
Yes
( ) No
36. Learner mentions history of screening/health
maintenance/immunizations, etc.
()
Yes
( ) No
Notes: vitamins, herbs, etc.
Notes: Any one mention is sufficient to score "yes."
37. Comments:
Family History (FHx)
38. Asks generally about Family History.
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
Notes: any disease runs in your family?, etc. The SP will have a position answer
to this question.
39. Establishes health status of father or age at and cause of death
Notes: Is your father living? If yes, how old is he and does he have any health
problems?
If no, how old was he when he died and what did he die of?
40. Establishes health status of mother or age at and cause of death
Notes: Is your mother living? If yes, how old is she and does she have any health
problems?
If no, how old was she when he died and what did she die of?
41. Establishes number of siblings and health status of each or age at and cause of
death.
Notes: Do you have any siblings? For each sibling ask:
Is your sibling living? If yes, how old is he/she and does he/she have any
health problems?
If no, how old was he/she when he died and what did he/she die of?
42. Asks about specific Family History related to current chief complaint.
()
Yes
()
No
Notes: Examples:
"Has anyone in the family had a disease or symptoms like this?"
"Are there any diseases in your family in this body system (would indicate
specific system)."
43. Comments:
Social History (SHx)
44. Relationship status.
()
()
Yes No
Notes: Typical question might be: Are you in a relationship with anyone? May or
may not follow up on answer to get more information about the relationship
for the purposes of this exam.
45. Employment status.
()
()
Yes No
Notes: At a minimum, must ask "what kind of work do you do" or a similar
question. If retired, just ask "what kind or work did you do."
46. Living situation.
()
()
Yes No
Notes: Typically would find out whether patient lives in house or apartment (or is
homeless), who with, etc. Any question is sufficient to score "yes."
47. Smoking history.
()
()
Yes No
Notes: If he/she has ever smoked need to find number of years and packs smoked
per day. If prior smoker and has stopped need to find out how many years
since he's smoked.
48. Alcohol intake.
()
()
Yes No
Notes: If yes, need to determine drinks/day (or week or month).
49. Recreational drug use.
()
()
Yes No
Notes: If yes, need to determine drug, quantity and frequency.
50. Sexual history.
Notes: At a minimum should determine:
()
()
Yes No
1. whether patient is sexually active
2. whether with men, women or both
3. is barrier protection used
51. Eating habits/diet.
()
()
Yes No
Notes: Any question about diet or eating habits will suffice.
52. Exercise/Activity
()
()
Yes No
Notes: Any question about exercise of level of activity will suffice.
53. Sources of stress.
()
()
Yes No
Notes: Any questions about whether patient experiences stress or whether there are
stressors in his/her life will suffice.
54. Support systems.
()
()
Yes No
Notes: Any questions about support of friends and/or family, a support system,
supportive environment or a question about being close to friends/family
will suffice
55. Comments:
Review of Systems (ROS)
Scoring for ROS
Student must ask at least 1 question for each system to score "yes."
56. General symptoms.
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
Notes: e.g. weight loss, fatigue, fever, chills
57. HEENT symptoms
Notes: e.g. blurry vision, sinus problems, sore throat
58. Breast symptoms.
Notes: e.g. discharge, mass, skin changes
59. Endocrine symptoms.
Notes: e.g. polyuria, polydipsia, polyphagia, heat/cold intolerance, history of
thyroid issues
60. Pulmonary symptoms.
Notes: e.g. hemoptysis, cough or dyspnea
61. Cardiovascular symptoms.
Notes: e.g. chest pain, palpitations, syncope
62. Gastrointestinal symptoms.
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
()
Yes
()
No
Notes: e.g. nausea or vomiting, change in bowel habits, diarrhea, black or tarry
stools, trouble swallowing, change in appetite or diet
63. GU symptoms.
Notes: e.g. dysuria, hematuria
64. Reproductive system symptoms
Notes: e.g. post menopausal or last menstrual period and postmenopausal bleeding,
pregnancy hx
65. Musculoskeletal symptoms.
Notes: e.g. pain, stiffness, swelling
66. Neurologic symptoms.
Notes: e.g. dizziness, numbness, weakness
67. Psychiatric symptoms.
Notes: e.g. mood, depression
68. Lymphatic symptoms.
Notes: e.g. swollen glands
69. Comments:
Head, Ears, Eyes, Nose, Throat & Cerv Nodes (HEENT)
70. Palpates the frontal and maxillary sinuses.
( ) Correct
Technique
( ) Incorrect
Technique
( ) Not
Done
71. Performs otoscopic examination.
( ) Correct
Technique
( ) Incorrect
Technique
( ) Not
Done
( ) Correct
Technique
( ) Incorrect
Technique
( ) Not
Done
Notes: Uses otoscope correctly; retracts ear upward and
back using the hand not holding the otoscope.
74. Performs fundoscopic examination.
Notes: Must darken the room, hold the instrument
correctly, get close enough to the patient, ask the
patient to focus on a distant point and use the
examiner's right eye to look at the patient's right
eye (and examiner's left eye to look at the patient's
left eye). If any of these items are omitted then the
exam is not done "correctly."
75. Examines oropharynx.
( ) Correct
Technique
( ) Incorrect
Technique
( ) Not
Done
76. Performs thyroid examination from behind the patient. ( ) Correct
Technique
Notes: Provides water for patient and asks him/her to
swallow, palpates both sides of the neck one side
at a time for lobes of thyroid
( ) Incorrect
Technique
( ) Not
Done
Notes: Looks in the mouth with a light.
77. Palpates lymph nodes in the head and neck. If "piano"
fingers used, learner does not score a check.
[ ] Under chin/jaw [submental
(under chin), submandibular (under
angle of jaw) tonsillar]
[ ] preauricular & postauricular (in
front of and behind ear)
[ ] occipital (base of skull)
[ ] anterior & posterior cervical
chain
78. Comments:
Cardiovascular (CV)
79. Examines patient from the patient's right side
( ) Yes
( ) No
80. Auscultates carotids bilaterally. Must ask patient to hold
breath.
( ) Correct
Technique
( ) Incorrect ( )
Technique Not
Done
81. Palpates carotids bilaterally one side at a time.
( ) Correct
Technique
( ) Incorrect ( )
Technique Not
Done
( ) Correct
Technique
( ) Incorrect ( )
Technique Not
Done
( ) Correct
Technique
( ) Incorrect ( )
Technique Not
Done
( ) Correct
Technique
( ) Incorrect ( )
Technique Not
Done
Notes: If both are palpated simultaneously that is incorrect. If
palpated before the carotids are auscultated, it is
incorrect.
82. Assesses JVP
Notes: Must raise the bed at least to a 30 degrees angle (or at
angle where you can see top of neck veins), have the
patient turn his/her head to the side and inspect the
jugular venous pulse for height and wave patterns.
This exam can be done with the patient turning his/her
head away from or towards the examiner.
83. Exposes anterior chest sufficiently to inspect the anterior
chest.
Notes: Should be exposed from the nipple line upwards.
84. Palpates to the anterior upper left of the sternum for lifts,
thrills, pulsations.
Notes: Above nipple line.
85. Palpates apical impulse at the apex of the heart.
( ) Correct
Technique
( ) Incorrect ( )
Technique Not
Done
( ) Correct
Technique
( ) Incorrect ( )
Technique Not
Done
87. Auscultates heart with bell in the tricuspid and mitral area ( ) Correct
Technique
Notes: down the left sternal border (tricuspid)
over the apex (mitral)
( ) Incorrect ( )
Technique Not
Done
Notes: In women the student or patient may need to displace
breast. To do so the student should use the back of
his/her hand or ask patient to do it herself. Women
may also need to hold up the underwire or elastic of
the bra.
86. Auscultates heart with the diaphragm in the correct 4
listening areas.
Notes: right second interspace (aortic area)
over left second interspace (pulmonic area),
down the left sternal border (tricuspid)
over the apex (mitral)
88. Palpates peripheral pulses bilaterally.
[ ] brachial (elbow)
[ ] radial (wrist)
[ ] femoral (groin)
[ ] popliteal (behind knee)
[ ] posterior tibial (behind the
inner ankle bone)
[ ] dorsalis pedis (top of foot)
89. Checks for pedal edema by pressing on the patient's shin
and/or ankles.
( ) Correct
Technique
( ) Incorrect ( )
Technique Not
Done
90. Comments:
Pulmonary (Pul)
91. Auscultates posteriorly (in the back)
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
Notes: 3 locations on each side comparing left to right.
Patient must be asked to breathe in and out through
mouth or take deep breaths. Stethoscope must
remain in contact with the skin throughout a full
cycle of inspiration & expiration to score "correct."
92. Auscultates anteriorly bilaterally (upper chest above or
below clavicles in front)
Notes: Patient must be asked to take deep breaths or breathe
in and out through mouth. Needs to listen at one
place on each side (right/left). Stethoscope must
remain in contact with the skin throughout a full
cycle of inspiration & expiration to score "correct."
93. Auscultates the right middle lobe - laterally under right
( ) Correct
arm pit or under R nipple/breast. Stethoscope must remain in Technique
contact with the skin throughout a full cycle of inspiration &
expiration to score "correct."
( ) Incorrect ( ) Not
Technique Done
94. Comments:
Abdomen & Inguinal Nodes (Abd)
95. Examines the abdomen standing at the patient's right side.
96. Auscultates the abdomen (for bowel sounds)
( ) Yes
( ) No
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique Done
Notes: prior to percussion or palpation for full credit. Only
needs to listen to one location. Cannot listen over
gown for full credit.
97. Percusses all 4 quadrants of the abdomen
Notes: Must be done after auscultation for full credit
98. Percusses the liver
Notes: Must percuss upper border from above and lower
border from below. Needs to start at the level of the
umbilicus or below.
99. Percusses over the splenic area and has patient take a
deep breath and tap long enough to determine whether the
percussion note changes
Notes: in the left 9th intercostal space between anterior
axillary and mid axillary line
100. Palpates the abdomen
Notes: Must do light and deep palpation in all 4 quadrants
for full credit. Can do light and deep at each
location OR do light at 4 quadrants then deep at 4
quadrants.
101. Palpates for hepatomegaly
Notes: May push up under the ribs while looking at
patient's head or hook under the ribs while facing
the patient's feet. In either technique must ask the
patient to take a deep breath.
102. Palpates for splenomegaly
Notes: Can do one-handed with patient supine or can use
both hands and place one hand under the patient's
back and instructs patient to turn on right side and
take a deep breath while the examiner feels under
the left ribs.
103. Comments:
Neuro Exam (Neuro)
104. CN II: Optic: fundoscopic
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
Notes: Must be in darkened room for full credit. Should
ask patient to focus on a distant point. Must get
close enough. All three criteria required for full
credit.
105. CN II: Optic: visual fields by confrontation
Notes: Has patient focus on nose or forehead;
Keeps hands 2-3 ft away from patient's eyes;
Check each central field with finger count (1,2,5)
or finger wiggle in each quadrant;
Tests each eye independently with patient covering
one eye at a time.
All instructions must be given to patient and all
steps done correctly for full credit.
106. CN II & III: Optic & Oculomotor: direct and
consensual pupil exam
Notes: Must do both for full credit. In direct pupil
contraction is noted when a light is shined that that
eye. For consensual, pupil contraction is noted
when a light is shined in the opposite eye.
107. CN III, IV, and VI: Oculomotor, Trochlear, and
Abducens - Check EOMs
Notes: The patient must be instructed to follow the
examiner's finger or a light without moving the
head.
108. CN III, IV, and VI: Oculomotor, Trochlear, and
Abducens - Pupil reaction to accommodation.
Notes: The patient must be told to focus on a distant object
in the midline then on an object close to the
patient's nose.
109. CN V: Trigeminal: Tests light touch (with cotton ball,
q tip cotton or finger tip) or temperature (tuning fork is
cold/must warm one side) using one modality on all three
areas bilaterally.
Notes: Must do bilaterally in all areas (temple, cheek,
chin) for full credit. Must touch lightly and cannot
rub area.
110. CN VII: Facial Test facial muscle strength: wrinkle
forehead/grimace/show teeth/smile
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
111. CN VIII: Acoustic: Checks hearing by finger rub or
whisper.
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
112. CN IX & X: Glossopharyngeal and Vagus: palatal
elevation
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
Notes: Must do one for full credit.
Notes: Have the patient say "ah" while looking at palate.
The learners are instructed NOT to do gag reflex.
Note that this may be combined with looking in the
patient's mouth.
113. CN XI: Spinal Accessory: shrug shoulders and head
turn against resistance
Notes: Must do both for full credit.
114. CN XII: Hypoglossal: stick out tongue; push out
tongue on each side and assess strength.
Notes: Must do both for full credit.
115. Sensation: Light touch arms & legs.
Notes: Must ask patient to close eyes.
Must test bilaterally.
Must test exact site (i.e. doesn't drag stimulus
across)
Must test both arms and legs.
116. Sensation: Sharp/dull arms & legs.
Notes: Must ask patient to close eyes.
Must test bilaterally asking “sharp or dull?”
Must test exact site (i.e. doesn't drag stimulus
across)
Must test both arms and legs.
117. Sensation: Vibration hands & feet.
Notes: Must ask patient to close eyes.
Must determine that patient feels vibration and not
simply touch.
Must test bilaterally with tuning fork on a bony
prominence.
Must test both hands and feet.
118. Sensation: Joint position sense of big toe bilaterally.
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
( ) Correct
Technique
( ) Incorrect ( ) Not
Technique
Done
Notes: Must ask patient to close eyes.
Must grip toe laterally and avoid touching nearby
digits which would give clues.
Ask patient to identify position (up or down).
Must test bilaterally.
119. Reflexes
Notes: Must check all of the following bilaterally for full
credit:
Biceps, Triceps, Brachioradialis, Patellar (knee
jerk), Achilles (ankle jerk) and Babinski (plantar)
120. Gait: regular gait, toe walking, heel walking, tandem
gait
Notes: must do all for full credit. Walking on toes and
heels will also fulfill ankle dorsiflexion and ankle
plantar flexion.
121. Romberg (Patient stands with eyes closed).
Notes: Patient should be instructed to stand with feet
together and eyes closed. Examiner should stand
close to patient to prevent injury. Both are required
for full credit.
122. Cerebellar function: dysmetria and ataxia: finger to
nose AND heel to shin
Notes: must be both bilaterally for full credit
123. Cerebellar function: dysdiadokinesia: rapidly
alternating movements
Notes: can do either one hand in the other or tap heel
repetitively
124. Comments:
Musculoskeletal Examination (PE-M/S)
125. Did the student palpate all joint
[ ] fingers
areas (for swelling, redness or warmth) [ ] hands
by identifying joint spaces and
[ ] wrists
comparing side to side
[ ] elbows
[ ] shoulders
[ ] hips
[ ] knees
[ ] ankles
[ ] toes
126. Did the student assess active
[ ] TMJ joint by opening/closing mouth and moving jaw
range of motion of the following joints side to side
bilaterally?
[ ] C spine (flexion/extension, rotation, lateral bending
to each side)
[ ] Back (flexion/extension, rotation, lateral bending to
each side)
[ ] Shoulder (abduction, forward flexion, horizontal
abduction, internal rotation, adduction, backward
flexion (extension), horizontal adduction, and external
rotation)
[ ] Elbow (flexion/extension)
[ ] Forearm (pronation/supination)
[ ] Wrist (flexion/extension, abduction/adduction,
ulnar/radial deviation)
[ ] MCP (flexion/extension, abduction/adduction)
metacarpophalangeal (knuckles)
[ ] PIP/DIP (flexion/extension) - fingers
[ ] HIP: (flexion/extension, internal/extension rotation,
abduction/adduction)
[ ] Knee: (flexion/extension, hyperextension)
[ ] Ankles: (dorsiflexion, inversion, plantar flexion,
eversion)
[ ] Toes: (flexion, extension)
127. Did the learner assess strength
against resistance bilaterally.
[ ] Shoulder abductors & adductors
[ ] Shoulder horizontal abductors & adductors
[ ] Shoulder internal & external rotation
[ ] Elbow biceps & triceps
[ ] Wrist flexors & extensors
[ ] Fingers abduction & adduction
[ ] Fingers grip
[ ] Hip flexors & extensors
[ ] Hip abductors & adductors
[ ] Knee flexors & extensors
[ ] Ankle dorsiflexion (stand on heels)
[ ] Ankle plantar flexors (stand on toes)
[ ] Ankle inverters & everters
Student of Concern & Performance Deficits (SOC)
128. Do you have concerns about this student?
()
Yes
()
No
Notes: Concerns may include: below average overall, below average in a single
section, concern about an area not included in the checklists.
129. Comments re skill deficits observed: