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 persons 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

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