Chiropractic Posture Chart 

Date: Doctor: _________________________________________

Patient’s Name: Ref #: __________________________________________

Date of Birth: Age: Gender: Male □ Female □

Insurance Details: ________________________________________________________________________________

Standing Posture
Scoring
Body Parts
L R
Head
Neck
Shoulders
Upper Back
Lower Back
Spine
Torso
Abdomen
Hips
Knees
Ankles

 
 
Prone Posture Supine Posture
Scoring Scoring
Body Parts Body Parts
L R L R
Head Head
Neck Neck
Shoulders Shoulders
Upper Back Upper Back
Lower Back Lower Back
Spine Spine
Torso Torso
Abdomen Abdomen
Hips Hips
Knees Knees
Ankles Ankles

  www.FreePrintableMedicalForms.com