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Lumbar/ Sacroilliac Evaluation
Name___________________________ DX_______________________________________________________ Date:__________
PMH_______________________________________________________________________________________________________
Physician_______________________________Next Appt___________________Onset_______________
Initial Evaluation:_____ Re-Evaluation:_____
Pain Rating_________
Funct. Rating__________
*PRECAUTIONS/ CONTRAINDICATIONS:______________________________________________
SUBJECTIVE: Radiating pain
R L Numbness/ Tingling R L
Pain with sitting Pain with Standing
Trouble sleeping _____# Hours/ night_____ Symptoms worse in A.M. P.M.
____________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
C/c:________________________________________________________________________________________________________
Occupation/Social Hx:_________________________________________________________________________________________
Hobbies/Sport:_______________________________________________________________________________________________
Pt. Goals:____________________________________________________________________________________________________
OBJECTIVE:
Observation: _____Rounded shoulders_____Forward head
mid-Thoracic Kyphosis
Lumbar lordosis
Gait:_______________________________________________________________________________________________________
Landmarks: (Standing) ( = high, =low, = equal, R = right, L = left): _________________________________________________
ROM / Strength:
Active
Trunk Flexion _____WNL
Trunk Ext
_____WNL
Trunk Rot. R: _____WNL
L: _____WNL
Trunk SB R: _____WNL
Trunk SB L: _____WNL
Knee ext.
Knee flex
DF
PF
Hip Flex
Hip Ext.
Hip ABD
Gr. Toe ext
MMT Strength
R
L
_____ P _____
_____ P _____
_____ P _____
_____ P _____
_____ P _____
_____ P _____
_____ P _____
_____ P _____
Painful
Painful
Painful
Painful
Painful
Painful
P
P
P
P
P
P
P
P
Tightness
Tightness
Tightness
Tightness
Tightness
Tightness
75%
75%
75%
75%
75%
75%
50%
50%
50%
50%
50%
50%
25%
25%
25%
25%
25%
25%
Non-Organic Signs
Tenderness
Superficial
Nonanatomic
Simulation
Axial loading
Rotation
other_________________
other_________________
other_________________
other_________________
other_________________
other_________________
Distraction (SLR) Regional
Weakness
Sensory
Overreaction
Patient Identifier
(3 / 5 positive)
Neurological Screen:
Sensation: _____WNL Other_____________________________
Reflexes:
Quads R_____L_____ Achilles R_____L_____
Flexibility:
(NT= normal, T= tight, VT= very tight)_______________________________________________________________
Name:___________________________________ __
DOB:_________
Landmarks:
Iliac Crest
ASIS
PSIS
ILA
Ischial Tub
Malleoli
Pubic Rami
Sacrum
R
Flexed
Palpation:__________________________________
___________________________________________
___________________________________________
___________________________________________
L
WNL
Level
Level
Level
Level
Level
Level
Level
Extended
Special Tests:
Slump Test
Gillet (Stork) Test
Standing Flexion (PSIS)
Trendelenburg Test
SLR
Supine to Sit Test
Fabre Test
Prone Knee Bend Test
R
+
+
+
+
+
+
+
+
L
+
+
+
+
+
+
+
+
Compression Test
Distraction Test
Gaenslen Test
Sacral Thrust Test
Thigh Thrust Test
R
+
+
+
+
+
L
+
+
+
+
+
( Cluster of of above + SI Sens .91, Spec .78)
SPRING PIVM testing (0-6) Normal = 3
(circle)
FLEX
SBL
SBR
RL
RR
EXT
L1
L2
Position Testing (lumbar):
L3
ERS: + Level________________________________
L4
FRS: + Level________________________________
L5
Treatment:__________________________________________________________________________________________________
ASSESSMENT: _____See Initial Eval Summary/ Plan of Care
____________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Rehabilitation Potential:
STG/LTG:
PLAN:
Good
Fair
Poor
_____See Initial Eval Summary/ Plan of Care
(Circle)
Therex
Ultrasound
HEP
Excellent
# Rx/ wk______ # wks______
Strengthening Stretching
EStim
Manual Therapy
Lumbar Stab. Bracing/ Taping
Avg. Pain Rating _____
Joint Mobs
ASTYM
Traction (Mechanical / Manual)
Moist Heat/ Cold Pack
Other:________________
Self Reported Functional Rating _____
Oswestry: _____
Therapist Signature:_________________________________________ Date:__________ Time:________
