DORN METHOD Documentation and Diagnosis Sheet: Date:________________________

Name:_______________________________________Gender:_______ Status:_______Birthday:____________

Address:______________________________________________________________________________________

Contact No:___________________________________________ E-Mail:_________________________________

Patient History/Complains:_______________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Scoliosis/Curvature Misalignment Spinal Column Misalignment Scoliosis/Curvature

From - To, Mark ( or ) Mark with X Posterior View Mark with X From - To, Mark ( or )
Comments: Comments:
C1 C1
C2 C2
C3 C3
C4 C4
C5 C5
C6 C6
C7 C7
Th 1 Th 1
Th 2 Th 2
Th 3 Th 3
Th 4 Th 4
Th 5 Th 5
Th 6 Th 6
Th 7 Th 7
Th 8 Th 8
Th 9 Th 9
Th 10 Th 10
Th 11 Th 11
Th 12 Th 12
L1 L1
L2 L2
L3 L3
L4 L4
L5 L5

Sacrum Left Side: Sacrum Right Side:

Higher Backwards Higher Backwards

Leg Length Left: Leg Length Right:

__________cm/inch longer __________cm/inch longer