FCE

Patient Info Employer Info Setup: Demographics Patient Name Medical Record Number Employer Occupation Job Title Referring Physician Other Physician Other Physician Diagnosis Evaluator Claims Adjustor Case Manager Medical Record Number Vocational Counselor Signed Consent Form? Gender Date of Birth Date of Assessment Date of Injury Date of Disability Date of Surgery Date of Surgery Date of Surgery Date of Surgery Time In Setup: Diagnostics Anthropometry Height Weight Dominance Pre-Evaluation Diagnostics Resting Heart Rate Resting Blood Pressure Limiting Factors Aerobic Weight Pain Rating Present Functional Pain Level Average Functional Pain Level Worst Functional Pain Level Least Functional Pain Level Setup: History History of Present Condition Past Medical History Setup: Records Reviewed Records Reviewed Setup: Present Status Present Status Setup: Medications Medications Setup: Assessment Purpose Assessment Purpose Job Demands: Vocational Status Current Work Status Physical Demands Obtained From Current Work Status Job Demands: Sit/Stand Sitting Standing Sitting Job Demands: Material Handling Floor to Waist Lift (Squat Lift) Occassional Floor to Waist Lift (Squat Lift) Frequent Floor to Waist Lift (Squat Lift) Constant Floor to Waist Lift (Squat Lift) 12 inches to Waist Lift (Power Lift) Occassional 12 inches to Waist Lift (Power Lift) Frequent 12 inches to Waist Lift (Power Lift) Constant 12 inches to Waist Lift (Power Lift) Shoulder Lift Occassional Shoulder Lift Frequent Shoulder Lift Constant Shoulder Lift Overhead Lift Occassional Overhead Lift Frequent Overhead Lift Constant Overhead Lift Job-Specific / Bend Lift Job-Specific / Bend Lift Bilateral Carry Occassional Bilateral Carry Frequent Bilateral Carry Constant Bilateral Carry Unilateral Carry Occassional Unilateral Carry Frequent Unilateral Carry Constant Unilateral Carry Push Occassional Push Frequent Push Constant Push Pull Occassional Pull Frequent Pull Constant Pull Unilateral Lift Occassional Pull Occassional Pull Occassional Pull Job Demands: Positional Tolerance Bending Squatting Sustained Squatting Repetitive Kneeling Sustained Kneeling Crawling Job Demands: Climbing Stairs Ladder Static Balancing Dynamic Balancing Job Demands: Upper Extremity Above Shoulder Reach Forward Reach Fine Motor Coordination Gross Motor Coordination Simple Grasp Firm Grasp Pinching Job Demands: Job Simulation Subhead Musculoskeletal Screen I Posture Posture Musculoskeletal Screen I Palpation Palpation Musculoskeletal Screen I Reflexes Reflexes Spinal: Cervical Goniometric Measurements (degrees) All AROM WNL All AROM WFL Cervical Flexion Cervical Extension Right Cervical Rotation Left Cervical Flexion Right Cervical Lat Flexion Left Cervical Lat Flexion Inclinometric Measurements

Cervical Flexion (50deg)

+/- 10% or 5° Max Angle Calvarium Angle T1 ROM Cervical Flexion Angle

Cervical Extension (60deg)

+/- 10% or 5° Max Angle Calvarium Angle T1 ROM Cervical Extension Angle

Cervical Ankylosis in Flexion/Extension

Cervical Left Lateral Bending (45deg)

+/- 10% or 5° Max Angle Calvarium Angle T1 ROM Cervical Lateral Flexion Angle

Cervical Right Lateral Bending (45deg)

+/- 10% or 5° Max Angle Calvarium Angle T1 ROM Cervical Lateral Flexion Angle

Cervical Ankylosis in Lateral Bending

Cervical Left Rotation (80deg)

+/- 10% or 5° Max Angle Rotation Angle

Cervical Right Rotation (80deg)

+/- 10% or 5° Max Angle Rotation Angle

Cervical Ankylosis in Rotation

Special Tests Compression Distraction Spurlings Test Swallowing Test Valsalva Maneuver L’Hermitte’s Sign Post Test Cervical Diagnostics Pain Rating Heart Rate Documentation Cervical Comments

Thoracic Flexion Validity

+/- 10%

Thoracic Left Rotation (30deg)

+/- 10% or 5° Max Angle T1 Reading T12 Reading Angle

Thoracic Right Rotation (30deg)

+/- 10% or 5° Max Angle T1 Reading T12 Reading Angle

Thoracic Ankylosis in Rotation

+/- 10% or 5° Post Test Thoracic Diagnostics Pain Rating Heart Rate Documentation Cervical Comments Spinal: Lumbar Goniometric Measurements (degrees) All AROM WNL All AROM WFL Trunk Flexion Trunk Extension Right Trunk Rotation Left Trunk Rotation Right Trunk Lat Flexion Left Trunk Lat Flexion Inclinometric Measurements

Lumbar Flexion (60deg)

+/- 10% or 5° Max Angle T12 ROM Sacral ROM Flexion Angle

Lumbar Extension (25deg)

+/- 10% or 5° Max Angle T12 ROM Sacral ROM Extension Angle

Straight Leg Rising (SLR), Left

+/- 10% or 5° SLR (Left)

Straight Leg Rising (SLR), Right

+/- 10% or 5° SLR (Right)

Straight Leg Rising (SLR), Validity

SLR Validity Max Angle Midsacrum

Lumbar Left Lateral Bending (25deg)

+/- 10% or 5° Max Angle T12 ROM Sacral ROM Bending Angle

Lumbar Right Lateral Bending (25deg)

+/- 10% or 5° Max Angle T12 ROM Sacral ROM Bending Angle

Lumbar Ankylosis in Lateral Bending

+/- 10% or 5° Special Tests Dural Stretch Lumbar Compression Lumbar Distraction ASIS Compression ASIS Distraction R/L/B Gilet’s Kernig Straight Leg Raise (Lasegue) Forward Torsion Backward Torsion Sacroiliac Provocation Post Test Lumbar Diagnostics Pain Rating Heart Rate Documentation Lumbar Comments Upper and Lower Extremities Lower Extremity ALL AROM WNL ALL PROM WNL ALL AROM WFL ALL PROM WFL ALL MMT is 5/5

	R AROM	R PROM	R MMT	L AROM	L PROM	L MMT
Hip Flexion
Hip Extension
Hip Adduction
Hip Abduction
Hip Internal Rotation
Hip External Rotation
Knee Flexion
Knee Extension
Ankle Dorsiflexion
Ankle Plantarflexion
Ankle Inversion
Ankle Eversion

Special Tests Hip Provocation Fabere Test Valgus Varus Knee Anterior Drawer Knee Posterior Drawer Lachman’s Test Pivot Shift Posterior Sag Test McMurray’s Test Apley’s Test Patellar Apprehension Test Grinding Test Posterior Lateral Complex Double Heel Raise Test Ankle/Foot Anterior Drawer Test Talar Tilt Test Thompson Test Post Lower Upper Extremity Diagnostics Pain Rating Heart Rate Documentation Lower Extremity Comments Upper and Lower Extremities Upper Extremity ALL AROM WNL ALL PROM WNL ALL AROM WFL ALL PROM WFL ALL MMT is 5/5

	R MMT	L MMT
Upper Trapezius
Middle Trapezius
Lower Trapezius
Rhomboids
Lower Trapezius
Lower Trapezius

	R AROM	R PROM	R MMT	L AROM	L PROM	L MMT
Shoulder Flexion
Shoulder Extension
Shoulder Adduction
Shoulder Abduction
Horizontal Adduction
Horizontal Abduction
Internal Rotation
External Rotation
Elbow Flexion
Elbow Extension
Supination
Pronation
Wrist Flexion
Wrist Extension
Ulnar Deviation
Radial Deviation
Digit Opposition

Special Tests Impingement Speed Test Hawkins Kennedy Empty Can Drop Arm Test Apprehension Test Sulcus Sign Obrien’s Test Crank Test Yerguson’s Test Adson’s Test Varus/Valgus Stress Test Phalens Tinel’s Reverse Phalens Finklesteins Post Upper Extremity Diagnostics Pain Rating Heart Rate Documentation Lower Extremity Comments Hand Thumb ALL AROM WNL ALL PROM WNL ALL AROM WFL ALL PROM WFL ALL MMT is 5/5

	R AROM	R PROM	R MMT	L AROM	L PROM	L MMT
Thumb MP Extension
Thumb MP Flexion
Thumb IP Extension
Thumb IP Flexion
Radial Abduction
Palmar Abduction
Thumb Adduction
Opposition
Total Active Motion

Hand Index ALL AROM WNL ALL PROM WNL ALL AROM WFL ALL PROM WFL ALL MMT is 5/5

	R AROM	R PROM	R MMT	L AROM	L PROM	L MMT
Index MP Extension
Index MP Flexion
Index PIP Extension
Index PIP Flexion
Index DIP Extension
Index DIP Flexion
Index Abduction
Index Adduction
Total Active Motion

Hand Middle ALL AROM WNL ALL PROM WNL ALL AROM WFL ALL PROM WFL ALL MMT is 5/5

	R AROM	R PROM	R MMT	L AROM	L PROM	L MMT
Middle MP Extension
Middle MP Flexion
Middle PIP Extension
Middle PIP Flexion
Middle DIP Extension
Middle DIP Flexion
Middle Abduction Radial
Middle Abduction Ulnar
Total Active Motion

Hand Ring ALL AROM WNL ALL PROM WNL ALL AROM WFL ALL PROM WFL ALL MMT is 5/5

	R AROM	R PROM	R MMT	L AROM	L PROM	L MMT
Ring MP Extension
Ring MP Flexion
Ring PIP Extension
Ring PIP Flexion
Ring DIP Extension
Ring DIP Flexion
Ring Abduction Radial
Ring Abduction Ulnar
Total Active Motion

Hand Little ALL AROM WNL ALL PROM WNL ALL AROM WFL ALL PROM WFL ALL MMT is 5/5

	R AROM	R PROM	R MMT	L AROM	L PROM	L MMT
Little MP Extension
Little MP Flexion
Little PIP Extension
Little PIP Flexion
Little DIP Extension
Little DIP Flexion
Little Abduction Radial
Little Abduction Ulnar
Total Active Motion

Post Hand Diagnostics Pain Rating Heart Rate Documentation Hand Comments Special Tests Finkelstein’s Test CMC Grind Test Watson Scaphold Shift Test TFCC Grind Test Allen Test Gamekeepers Test Tinel’s Test Phalen’s Test Froment’s Sign Test Wartenberg’s Sign Test Jeanne’s Sign Test Musculoskeletal Screen II Orthotics/Assitive Devices Devices Orthotics/Assistive Devices Musculoskeletal Screen II Circumferential/Volumetric Measurements What type of measurement is being used?

Anatomical Location	L Pre	L Post	R Pre	R Post

Circumferential/Volumetric Measurements Musculoskeletal Screen II Two Point Discrimination Musculoskeletal Screen II Sharp/Dull Awareness Musculoskeletal Screen II Sensation Comments Self Report Sensation Two-point and Sharp/Dull Musculoskeletal Screen II Semmes Weinstein Musculoskeletal Screen II Lower Extremity Sensation Lower Extremity Sensation ROP: Waddell Signs Subhead ROP: McGill Questionnaire Subhead ROP: Ransford Pain Drawing Subhead ROP: Oswestry Low-Back Questionnaire Subhead ROP: Oswestry Neck Questionnaire Subhead ROP: Fear Avoidance Beliefs Subhead Upper Extremity: Grip Testing Subhead Upper Extremity: Pinch Testing Subhead Upper Extremity: Fine Motor Coordination Subhead
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Non-Material Handling: Walking Subhead Non-Material Handling: Reaching Subhead Non-Material Handling: Above Shoulder Reaching Subhead Non-Material Handling: Bending Subhead Non-Material Handling: Squatting Subhead Non-Material Handling: Sustained Squatting Subhead Non-Material Handling: Sustained Kneeling Subhead Non-Material Handling: Repetitive Kneeling Subhead Non-Material Handling: Crawling Subhead Non-Material Handling: Static Balance Subhead Non-Material Handling: Dynamic Balance Subhead
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Frequent Material Handling: Squat Lift Subhead Frequent Material Handling: Power Lift Subhead Frequent Material Handling: Shoulder Lift Subhead Frequent Material Handling: Overhead Lift Subhead Frequent Material Handling: Bilateral Carry Subhead Frequent Material Handling: Unilateral Lift Subhead Frequent Material Handling: Unilateral Lift Subhead Frequent Material Handling: Pushing/Pulling Subhead Job Simulated Functional Ability: Task 1 Subhead Job Simulated Functional Ability: Task 2 Subhead Job Simulated Functional Ability: Task 3 Subhead Job Simulated Functional Ability: Task 4 Subhead Job Simulated Functional Ability: Task 5 Subhead Frequent Material Handling: Squat Lift Subhead Frequent Material Handling: Power Lift Subhead Frequent Material Handling: Shoulder Lift Subhead Frequent Material Handling: Overhead Lift Subhead Frequent Material Handling: Bilateral Carry Subhead Frequent Material Handling: Unilateral Lift Subhead Frequent Material Handling: Unilateral Lift Subhead Frequent Material Handling: Pushing/Pulling Subhead Sit/Stand/Climb: Stair Climbing Subhead Sit/Stand/Climb: Ladder Climbing Subhead Sit/Stand/Climb: Sitting/Standing Subhead