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OccuPro Functional Capacity Evaluation Documentation Tool
OCCUPRO, LLC © 2014 www.occupro.net 1
Assessment Setup Demographics
Client Name:
Medical Record Number:
Employer:
Occupation:
Job Title:
Referring Doctor:
Other Doctor:
Other Doctor:
Diagnosis:
Evaluator:
Claims Adjustor:
Case Manager:
Attorney:
Gender: Male Female
Date of Birth:
Date of Eval:
Date of Injury:
Date of Surgery 1:
Date of Surgery 2:
Date of Surgery 3:
Date of Surgery 4:
Other:
Time In:
Time Out:
Basic Diagnostics Anthropometry
Height: inches
Weight: pounds
Dominance: Right Handed Left Handed
Ambidextrous
Pre-Evaluation Diagnostics
Resting Heart Rate: bpm
Resting Blood Pressure: mmHg
Resting Respiratory Rate: /min
Limiting Factors
Aerobic Limiting Factor: bpm
Weight Limiting Factor: pounds
Pain Rating
Following the presentation of the OccuPro
Functional Pain Scale did this client report that they
understood the pain scale?
Present Functional Pain Level: 0 1 2 3 4 5 6 7 8 9 10
Average Functional Pain Level: 0 1 2 3 4 5 6 7 8 9 10
Worst Functional Pain Level: 0 1 2 3 4 5 6 7 8 9 10
Least Functional Pain Level: 0 1 2 3 4 5 6 7 8 9 10
Following this client's report of their present,
average, worst and least pain did they report a
reliable level of pain prior to functional testing based
on OccuPro Functional Pain Scale
History of Present Condition
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Past Medical History
Present Status
Medications
Assessment Purpose
Job Demand Analysis Vocational Status
Current Work Status: Off at Work Light/Modified Duty Work Full Time Light/Modified Duty Work Part Time
Full Duty Work Part Time Full Duty Work Full Time
Physical Demands Obtained From: On-Site Job Demands Analysis Job Description
Dictionary of Occupational Titles Client Verbal Discussion with Employer
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Vocational Status:
The physical demands of the job should be documented on the Job Demands Match worksheet.
Musculoskeletal Testing
Posture
Palpation
Reflexes
Cervical ROM
Goniometric Measurements (Degrees or Percentage)
Cervical Flexion: °
Cervical Extension: °
Right Cervical Rotation: °
Left Cervical Rotation: °
Right Cervical Lat Flexion: °
Left Cervical Lat Flexion: °
Inclinometric Measurements
Cervical Flexion (60°)
+/-10 % or 5°
Max Angle
Calvarium Angle
T1 ROM
Angle
Cervical Extension (75°)
+/-10 % or 5°
Max Angle
Calvarium Angle
T1 ROM
Angle
Cervical Ankylosis in Lateral Bending:
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Cervical Left Rotation (80°)
+/-10 % or 5° Rotation Angle:
Max Angle
Cervical Right Rotation (80°)
+/-10 % or 5° Rotation Angle:
Max Angle
Cervical Ankylosis in Rotation:
Lumbar ROM
Goniometric Measurements (%)
Trunk Flexion:
Trunk Extension:
Right Trunk Rotation:
Left Trunk Rotation:
Right Trunk Lat Flexion:
Left Trunk Lat Flexion:
Inclinometric Measurements
Lumbar Flexion (60°) T12 ROM
+/- 10% or 5° Sacral ROM
Max Angle Flexion Angle
Lumbar Extension (25°) T12 ROM
+/- 10% or 5° Sacral ROM
Max Angle Angle
Straight Leg Rising (SLR), Left
+/- 10 % or 5° SLR (Left)
Straight Left Rising (SLR), Right
+/- 10% or 5° SLR (Right)
Straight Leg Rising (SLR), Validity
SLR Validity Midsacrum
Max Angle
Lumbar Left Lateral Bending (25°) T12 ROM
+/- 10% or 5° Sacral ROM
Max Angle Angle
Lumbar Ankylosis in Lateral Bending
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Thoracic ROM
Angel of Minimum Kyphosis T1 Reading
+/- 10% or 5° T12 Reading
Angle
Thoracic Flexion (50°) T1 Reading
+/- 10% or 5° T12 Reading
Max Angle Angle
Thoracic Flexion Repro(50°) T1 Reading
+/- 10% or 5° T12 Reading
Max Angle Angle
Thoracic Left Rotation (30°)
+/-10 % or 5° Rotation Angle:
Max Angle
Thoracic Right Rotation (30°)
+/-10 % or 5° Rotation Angle:
Max Angle
Thoracic Ankylosis in Rotation:
Spine Musculoskeletal Testing Comments
Lower Extremity ROM/MMT
Location R AROM R PROM R MMT L AROM L PROM L MMT Hip Flexion
Hip Extension Hip Adduction Hip Abduction
Hip Internal Rotation Hip External Rotation
Knee Flexion Knee Extension
Ankle Dorsiflexion Ankle Plantarflexion
Ankle Inversion Ankle Eversion
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Upper Extremity ROM/MMT
Location R AROM R PROM R MMT L AROM L PROM L MMT Shoulder Elevation Shoulder Flexion
Shoulder Extension Shoulder Abduction Shoulder Abduction
Horizontal Adduction Horizontal Abduction
External Rotation Internal Rotation Elbow Flexion
Elbow Extension Supination Pronation
Wrist Flexion Wrist Extension Ulnar Deviation Radial Deviation Digit Oposition
Upper Extremity and Lower Extremity Comments
Upper Extremity Testing
Orthotics/Assistive Devices
Devices:
None
Neoprene Lumbar Corset
Ankle Brace
Knee Brace
Shoe/Sole Inserts
Straight Cane
Quad Cane
Walker
Reacher
AFO
Comments:
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Circumferential or Volumetric Measurements
What type of measurement is utilized?
Anatomical
Position
Right Pre
Measurement
Right Post
Measurement
Left Pre
Measurement
Left Post
Measurement
Circumferential/Volumetric Measurement Comments:
Two Point Discrimination
Sharp Dull Awareness
Two Point/Sharp Dull Comments
Musculoskeletal Testing
Semmes Weinstein Monofilament Testing
Lower Extremity Sensation
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Reliability of Pain Waddell Signs
Superficial Tenderness: Positive Negative
Simulation Test: Positive Negative
Distraction: Positive Negative
Regional Disturbances: Positive Negative
Overreaction to Test: Positive Negative
Comments:
Psychometric Testing
McGill Pain Questionnaire: Reliable Unreliable
Ransford Pain Drawing: Reliable Unreliable
Oswestry Low Back: Reliable Unreliable
Oswestry Neck: Reliable Unreliable
Comments:
Upper Extremity Testing
Grip Testing
Does this client present with musculoskeletal based distal upper extremity weakness secondary to a diagnosis
that has caused this distal upper extremity weakness? Right? Yes No Left? Yes No
Grip Strength Group Strength Coefficients of Variation Norms
R L R L R L
Trial 1 CoV(%) Mean
Trial 2 *A coefficient of variation greater than Range
Trial 3 15% denotes an inconsistent test.
Five Span Grip
Position 1 Position 2 Position 3 Position 4 Position 5
Right
Left
Rapid Exchange Grip Strength Test R L
Max Poundage Noted in Tests 5-8
Post Grip Testing Diagnostics
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Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Can tolerate simple grasping within the following frequency:
N/A Avoid Occasional Frequent Continuous
Can tolerate firm grasping within the following frequency:
N/A Avoid Occasional Frequent Continuous
Grip Comments:
Pinch Testing
Key Pinch Key Pinch Coefficients of Variation Key Pinch Norms
R L R L R L
Trial 1 CV (%) Mean
Trial 2 *A coefficient of variation greater than Range
Trail 3 15% is an inconsistent test.
Palmar Pinch Palmar Pinch Coefficients of Variation Palmar Pinch Norms
R L R L R L
Trial 1 CV (%) Mean
Trial 2 *A coefficient of variation greater than Range
Trial 3 15% is an inconsistent test.
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Tip Pinch Tip Pinch Coefficients of Variation Tip Pinch Norms
R L R L R L
Trial 1 CV (%) Mean
Trial 2 *A coefficient of variation greater than Range
Trial 3 15% is an inconsistent test.
Post Pinch Testing Diagnostics
Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate pinching within the following frequency:
N/A Avoid Occasional Frequent Continuous
Pinch Comments:
Fine Motor Coordination
Purdue Pegboard
Right Hand Performed (30 sec): Left Hand Performed (30 sec):
Both Hands Performed (30 sec): Assembly Performed (60 sec):
Moberg’s Pick up Test
Eyes Open (10 – 14 sec)
Trial 1 Right Hand: sec Trial 2 Right Hand: sec
Trial 1 Left Hand: sec Trial 2 Left Hand: sec
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Eyes Closed (within 2 sec)
Trial 1 Right Hand: sec Trial 2 Right Hand: sec
Trial 1 Left Hand: sec Trial 2 Left Hand: sec
Post Fine Motor Testing Diagnostics
Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate fine motor within the following frequency:
N/A Avoid Occasional Frequent Continuous
Fine Motor Comments:
Gross Motor Coordination
Gross Motor Coordination
Box and Block Right Left Post Gross Motor Diagnostics
Right Hand Count Mean Pain Rating 1 2 3 4 5 6 7 8 9 10
Left Hand Count Range Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
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Client can tolerate Gross Motor Coordination within the following frequency?
N/A Avoid Occasional Frequent Continuous
Non-Material Handling
Fast-Paced Walking Post Fast-Paced Walking Diagnostics
Assistive Device? No Yes Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Stride? Even Uneven
Splinting? No Yes
Holding? No Yes
Gait? Non-Antalgic Gait Right Antalgic Gait Left Antalgic Gait
100 Yard Walking Abilities? seconds
Prolonged Walking Post Prolonged Walking Diagnostics
Assistive Device? No Yes Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Stride? Even Uneven
Splinting? No Yes
Holding? No Yes
Gait? Non-Antalgic Gait Right Antalgic Gait Left Antalgic Gait
100 Yard Walking Abilities? seconds
Self Reported Walking Abilities minutes
Prolonged Walking Abilities minutes
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
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Client can tolerate walking within the following frequency:
N/A Avoid Occasional Frequent Continuous
Fast Paced Walking Comments
Prolonged Walking Comments
Forward Reaching Post Reach x1 Diagnostics
Reaching x1 Pain Rating 0 1 2 3 4 5 6 7 8 9 10
History of neck/shoulder injuries? No Yes Heart Rate bpm
Percent of full forward reach ____
Speed? Slow Average Fast
Scapulohumeral Rhythm Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Crepitus? No Palpable Audible Painful
Reaching x10 Post Reach x10 Diagnostics
Percent of full forward reach _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed Slow Average Fast Heart Rate bpm
Scapulohumeral Rhythm Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Crepitus? No Palpable Audible Painful
Reaching x10 Fast Post Reach x10 Fast Diagnostics
Percent of full forward reach _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed Slow Average Fast Heart Rate bpm
Scapulohumeral Rhythm Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Crepitus? No Palpable Audible Painful
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
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Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate forward reaching within the following frequency:
N/A Avoid Occasional Frequent Continuous
Forward Reaching Comments
Above Shoulder Reaching Post Reach x1 Diagnostics
Reaching x1 Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Percent of full above shoulder reach _____ Heart Rate bpm
Speed? Slow Average Fast
Scapulohumeral Rhythm Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Crepitus? No Palpable Audible Painful
Reaching x10 Post Reach x10 Diagnostics
Percent of full above shoulder reach _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Scapulohumeral Rhythm Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Crepitus? No Palpable Audible Painful
Reaching x10 Fast Post Reach x10 Fast Diagnostics
Percent of full above shoulder reach _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Scapulohumeral Rhythm Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Crepitus? No Palpable Audible Painful
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Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate above shoulder reaching within the following frequency:
N/A Avoid Occasional Frequent Continuous
Above Shoulder Reaching Comments
Bending Post Bend x1 Diagnostics
Bend x1 Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Percent of full forward bend _____ Heart Rate bpm
Speed? Slow Average Fast
Movement Pattern? Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Hamstring Tightness? No Deficits Right Left Bilateral
Bend x10 Post Bend x10 Diagnostics
Percent of full forward bend _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Movement Pattern? Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Hamstring Tightness? No Deficits Right Left Bilateral
Bending x10 Fast Post Bend x10 Fast Diagnostics
Percent of full forward bend _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Movement Pattern? Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Hamstring Tightness? No Deficits Right Left Bilateral
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Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate bending within the following frequency:
N/A Avoid Occasional Frequent Continuous
Bending Comments
Squatting Post Squat x1 Diagnostics
Squatting x1 Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Percent of full squat _____ Heart Rate bpm
Speed? Slow Average Fast
Movement Pattern? Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Equal Weight Bearing? No Yes
Crepitus? No Palpable Audible Painful
Squatting x10 Post Squat x10 Diagnostics
Percent of full squat _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Movement Pattern? Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Equal Weight Bearing? No Yes
Crepitus? No Palpable Audible Painful
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
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Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate Squatting within the following frequency:
N/A Avoid Occasional Frequent Continuous
Squatting Comments
Sustained Squatting
This test is best administered in a job simulation fashion
Description of job simulated sustained squatting
Sustained Squatting minutes requested?_____ Post Sust. Squat Diagnostics
Sustained Squatting minutes achieved? _____ Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Heart Rate bpm
Movement Pattern? Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Equal Weight Bearing? No Yes
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
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Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Can tolerate Sustained Squatting within the following frequency?
N/A Avoid Occasional Frequent Continuous
Sustained Kneeling Post Sustained Kneel Diagnostics
Time Tolerated: min Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Movement Pattern? Normal Abnormal Heart Rate bpm
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Equal Weight Bearing? No Yes
Requires Upper Extremity Assistance? No Yes
Crepitus? No Palpable Audible Painful
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Can tolerate sustained kneeling within the following frequency:
N/A Avoid Occasional Frequent Continuous
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Repetitive Kneeling
Kneeling x10 Post Kneel x10 Diagnostics
Percent of full kneel _____ Pain Rating 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Movement Pattern? Normal Abnormal
Pain Correlates with Diagnosis? No Yes
Compensatory Technique? No Yes
Equal Weight Bearing? No Yes
Requires Upper Extremity Assistance? No Yes
Crepitus? No Palpable Audible Painful
Can tolerate repetitive kneel within the following frequency?
N/A Avoid Occasional Frequent Continuous
Kneeling comments
Crawling
Can client tolerate 1-20 minutes of crawling? Yes / No Post Crawling Diagnostics
Can client tolerate 21-40 minutes of crawling? Yes / No Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Can client tolerate 41-60 minutes of crawling? Yes / No Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate crawling within the following frequency:
N/A Avoid Occasional Frequent Continuous
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Crawling Comments:
Static Balance
Romberg Test? sec Post Static Balance Diagnostics
Sharpened Romberg? sec Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Functional Reach? inches Heart Rate bpm
Single leg stance right lower extremity sec
Single leg stance left lower extremity sec
Single leg stance eyes closed right lower extremity sec
Single leg stance eyes closed left lower extremity sec
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate static balance within the following frequency?
N/A Avoid Occasional Frequent Continuous
Dynamic Balance
Gait Level Surface Pass Fail Post Dynamic Balance Diagnostics
Change in gait speed Pass Fail Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Gait with horizontal head turns Pass Fail Heart Rate bpm
Gait with vertical head turns Pass Fail
Gait with pivot turn Pass Fail
Step over obstacle Pass Fail
Gait with narrow base of support Pass Fail
Gait with eyes closed Pass Fail
Ambulating Backward Pass Fail
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Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Can tolerate dynamic balance within the following frequency?
N/A Avoid Occasional Frequent Continuous
Balance Comments
Occasional Material Handling
Pre-Diagnostics
Include text about the importance of the pre-handling diagnostics, their meaning and what is expected of the
clinician during this portion of the assessment, etc., etc., etc.
Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Heart Rate bpm
Job Specific/Bending
Weights Handled Post Job Specific Lift Diagnostics
Peak Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight lbs Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
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Squat Lift
Weights Handled Post Squat Lift Diagnostics
Peak Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight lbs Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Power Lift Weights Handled Post Power Lift Diagnostics
Peak Weight lbs Lift Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight lbs Lift Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Shoulder Lift
Weights Handled Post Shoulder Lift Diagnostics
Peak Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight lbs Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
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Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Overhead Lift
Weights Handled Post Overhead Lift Diagnostics
Peak Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight lbs Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Two Handed Lifting Comments
Client’s overall lifting body mechanics
Two Handed Lifting Comments
Unilateral Lift
Weights Handled Post Unilateral Lift Diagnostics
Peak Weight lbs Pain Rating 1 2 3 4 5 6 7 8 9 10
Occasional Weight lbs Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
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Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Unilateral Lifting Comments
Bilateral Carry
Weights Handled Post Bilateral Carry Diagnostics
Peak Weight lbs Bilateral Carry Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight lbs Bilateral Carry Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Bilateral Carry Comments
Unilateral Carry
Weights Handled Post Unilateral Carry Diagnostics
Peak Weight lbs Unilateral Carry Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight lbs Unilateral Carry Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
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Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Unilateral Carry Comments
Pushing and Pulling
Pushing Weights Handled Post Pushing Diagnostics
Peak Weight HFP Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight HFP Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Pulling Weights Handled Post Pulling Diagnostics
Peak Weight HFP Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Occasional Weight HFP Heart Rate bpm
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
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Pushing and Pulling Comments
Job Simulated Functional Abilities Task 1
Title of Job Sim. Performed:
Description of Job Simulated Activity:
Post Task Diagnostics
Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Heart Rate bpm
Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate Task 1 within the following frequency:
N/A Avoid Occasional Frequent Continuous
Client’s ability to perform job simulated activity:
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Task 2
Title of Job Sim. Performed:
Description of Job Simulated Activity:
Post Task Diagnostics
Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Heart Rate bpm
Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate Task 1 within the following frequency:
N/A Avoid Occasional Frequent Continuous
Client’s ability to perform job simulated activity:
Frequent Material Handling Squat Lift
Pre Handling Diagnostics
Heart Rate bpm
Weights Handled Post Squat Lift Diagnostics
Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Frequent Weight lbs Heart Rate bpm
Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
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Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Power Lift
Pre Handling Diagnostics
Heart Rate bpm
Weights Handled Post Power Lift Diagnostics
Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Frequent Weight lbs Heart Rate bpm
Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Shoulder Lift
Pre Handling Diagnostics
Heart Rate bpm
Weights Handled Post Shoulder lift Diagnostics
Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Frequent Weight lbs Heart Rate bpm
Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
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Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Overhead Lift
Pre Handling Diagnostics
Heart Rate bpm
Weights Handled Post Overhead Lift Diagnostics
Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Frequent Weight lbs Heart Rate bpm
Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Bilateral Carrying
Pre Handling Diagnostics
Heart Rate bpm
Weights Handled Post Bilateral Carry Diagnostics
Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Frequent Weight lbs Heart Rate bpm
Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
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Unilateral Lift
Pre Handling Diagnostics
Heart Rate bpm
Weights Handled Post Unilateral Lift Diagnostics
Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Frequent Weight lbs Heart Rate bpm
Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Unilateral Carry
Pre Handling Diagnostics
Heart Rate bpm
Weights Handled Post Unilateral Carry Diagnostics
Peak Frequent Weight lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Frequent Weight lbs Heart Rate bpm
Frequent/Occasional % Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
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Push/Pull
Pre Handling Diagnostics
Heart Rate bpm
Weights Handled Post Push and Pull Diagnostics
Push Peak Freq. Wt. horz force lbs Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Push Freq. Wt. horz force lbs Heart Rate bpm
Pull Peak Freq. Wt. horz force lbs Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Pull Freq Wt. horz force lbs
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Comments
Clients overall lifting body mechanics
Frequent Lifting Comments:
Sit/Stand/Climb
Stair Climbing
Pre Stairs Diagnostics: Heart Rate bpm
36 Steps Completed (Occasional) Post 36 steps Diagnostics
Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Reciprocal foot over foot gait? No Yes
Compensatory Techniques? No Yes
Upper Extremity Assistance? No Mild Moderate Significant
Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait
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72 Steps Completed (Frequent) Post 72 steps Diagnostics
Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Reciprocal foot over foot gait? No Yes
Compensatory Techniques? No Yes
Upper Extremity Assistance? No Mild Moderate Significant
Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait
108 Steps Completed (Constant) Post 108 steps Diagnostics
Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Reciprocal foot over foot gait? No Yes
Compensatory Techniques? No Yes
Upper Extremity Assistance? No Mild Moderate Significant
Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate stair climbing within the following frequency:
N/A Avoid Occasional Frequent Continuous
Stair Climbing Comments
Ladder Climbing
Pre Ladder Climbing Diagnostics: Heart Rate bpm
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20 Ladder Rungs Completed (Occasional) Post 20 Ladder Diagnostics
Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Reciprocal foot over foot gait? No Yes
Compensatory Techniques? No Yes
Upper Extremity Assistance? No Mild Moderate Significant
Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait
60 Ladder Rungs Completed (Frequent) Post 60 Ladder Rungs Diagnostics
Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Reciprocal foot over foot gait? No Yes
Compensatory Techniques? No Yes
Upper Extremity Assistance? No Mild Moderate Significant
Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait
100 Ladder Rungs Completed (Constant) Post 100 Ladder Rungs Diagnostics
Time to complete seconds Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Speed? Slow Average Fast Heart Rate bpm
Climbing Safety Issues? No Yes Perceived Exertion 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Reciprocal foot over foot gait? No Yes
Compensatory Techniques? No Yes
Upper Extremity Assistance? No Mild Moderate Significant
Gait Pattern? Non Antalgic Gait Right Antalgic Gait Left Antalgic Gait
Limiting Factors
N/A Increased Pain Mechanical Changes Mechanical Deficits Compensatory Techniques Maximum Effort Inadequate Strength
Client Anxiety Safety Concern Evaluator Stopped Client Terminated General Fatigue Limited Range of Motion Poor Posture
Self Limiting Behaviors Noted Heart Rate Exceeds Aerobic Limiter Sensation Extra Ordinary Muscle Recruitment
Pain sign/Symptoms
Client reposts and increase in pain? Yes No (If Yes then answer the next three questions)
Client exhibited an increase in heart rate? Yes No
Client exhibited a true pain behavior? Yes No
Client exhibited an associated mechanical change/deficit? Yes No
Client can tolerate ladder climbing within the following frequencies:
N/A Avoid Occasional Frequent Continuous
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Ladder Climbing Comments
Total Sitting
Within the last week, in a 24 hour period how many hours are you in a lying down position?
How many hours were you sitting prior to coming to this evaluation?
How many hours did it take you to drive to this evaluation?
How many hours do you anticipate being in a sitting position after this evaluation?
How many hours total did the client sit during this evaluation?
How many hours total could you sit during the course of the day?
At One Tim Sitting
What is the longest the client sat at one time during this evaluation?
How many hours at once could you tolerate sitting before needing to change positions?
How many hours are left in the 24 hour day? add up the red questions
Total Standing
How many hours were you in a standing position prior to coming to this evaluation?
How many hours total did the client stand during this evaluation?
How many hours do you anticipate being in a standing position after this evaluation?
How many hours total could you stand during the course of a day?
At One Time Standing
What was the longest this client stood during this evaluation?
How many hours at once could you tolerate standing before needing to change positions?
Red plus Green should equal 22 or more hours to capture a 24 hour day
Post Sit/Stand Diagnostics
Pain Rating 0 1 2 3 4 5 6 7 8 9 10
Heart Rate bpm
Sitting and Standing Comments
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Results & Recommendations
Evaluations Results/Summary
Recommendations