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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:________