POSTURE

EXAMINATION FORM

Date: ________________

Name: _______________

Surname: ____________

Gender: M / F

Date of birth: __________

General Examination

a. Posterior view

1. Achilles tendon and feet: Right _________

Left

2. Knees (genu varum/genu

valgum) _________________________________

3. Pelvic balance

(posterior/superior iliac spine) ________________

4. Scapulae (height, distance from

spine, rotation) ____________________________

5. Shoulder line ___________________________

6. Neck __________________________________

7. Symmetry of fat folds (pelvis,

waist, neck) ______________________________

8. Spinal column (scoliosis) __________________

b. Lateral view

1. Feet arches ____________________________

2. Knees (hyperextension) ___________________

3. Pelvis (posterior/anterior tilt) _______________

4. Spinal curves (kyphosis /

lordosis / flat back) _________________________

5. Shoulder position ________________________

6. Head position (cervical lordosis) ____________

c. Anterior view

1. Feet ____________________

2. Knees ___________________

3. Pelvis (anterior superior iliac

spine)

4. Shoulders height __________

5. Neck/Head _______________

FUNCTIONAL TESTS

1.__________________________________________________________Length of spinal column (C7-

S1) __________________________________________

Standing ____________ Forward bending ____________

2.__________________________________________________________General flexibility test

Legs straight ___________________________________

Forward bending with knees bent ___________________

3.___________________________________________Hamstrings flexibility (SLR): Right Left

4.__________________________________________________________Quadratus lumborum flexibility

5.______________________________________________Thomas Test for iliopsoas flexibility: Right

____________________________________ Left ______

6.__________________________________________________________Abdominal muscle strength

7.___________________________________________________________Ability to flatten lower back to

floor (lying supine) ______________________________

8.________________________________________Range of shoulder motion: Right Left

9.____________________________________________Length of lower extremities: Right Left

10.__________________________________________________________Back muscle strength:

Cervical erectors ________________________________

Erector spinae __________________________________

Scapulae adductors _____________________________

11.Shoulder girdle strength:

Abduction: Right __________ Left ______________

Adduction: Right __________ Left ______________

Flexion: Right __________ Left ______________

Extension: Right __________ Left ______________

12._________________________________Static balance: Right leg Left leg

13.__________________________________________________________Dynamic balance

14.__________________________________________________________Forward walking (general

evaluation - broad/narrow support base, movement balance, movement flow,

coordination) ___________________________________

X-rays, medical documents and previous diagnoses:

General evaluation:

Recommended treatment (indications/contraindications):

TREATMENT REPORT AND DEFINITION OF AIMS

Date ________________________

Name _______________________________________________________________

Age

Activity duration ______________________

Disorder treated

Type of activity: Individual/Group/Integrated (circle one)

Location of activity _________________________________

1. Details of the problems requiring treatment (in reference to the posture and motor tests).

2. Other aspects affecting the person’s condition and the treatment process

(reference to family, cognitive emotional and social aspects, level of motivation,

cooperation, etc.)

3. Treatment aims and content matter for the coming months:

a.

b.

Treatment summary report

Date _________________

Name _______________________________________ Age

Activity duration ______________________ Disorder treated

1. Entry condition of the person at the beginning of treatment.

2. Details of treatment goals and work method selected for attaining them.

3. Persons condition today (improvement/worsening of condition).

4. Recommendations for further treatment of the person.

5. General comments about treating the person.

Name of therapist/instructor

SELF-EXERCISE FORM

Name ____________________________________ Date

DETAILS OF EXERCISE (DRAWING) NUMBER OF REPETITIONS EMPHASIS

FOR PERFORMANCE

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