Subjective Examination – The Recovery Lab

Name *

First

Last

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date / Time

Date

Time

Where Is The Pain?

How intense is the pain? on a scale of 1-10, 1 being at least

Observation Of Posture - Notes

Observation Of Muscle Form - Notes

Observation Of Soft Tissue - Note

Observation Of Gait - Note

Do you have any difficulties getting to sleep?

What position is most comfortable/uncomfortable?

What's your normal sleeping position?

What is your normal sleeping position?

What is your present sleeping position?

Do your symptoms keep you awake at night?

If so, which symptoms?

How many times in the past week?

How many times in a night?

How long does it take to get back to sleep?

General Health?

Weight Loss

Yes
No

Rheumatoid Arthritis

Yes
No

Drug Therapy

Yes
No

X RAY/MRI

Yes
No

Neuropathy History

Yes
No

Active ROM

Plantar Flexion/Plantar Flexion
Second Choice
Third Choice

Special Test

Navicular Drop Test
Anterior Draw Test
Subtalar Joint Instability Test
Ankle Impingement Syndrome

Passive ROM

First Choice
Second Choice
Third Choice

Red Flags

Bone Tenderness Of The Navicular
Bone Tenderness Of The Base Of The 5th Metatarsal
Inability To Bear Weight

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