HEALTH SCREENING AND RISK ASSESSMENT FORM

DATE: THERAPIST:

CLIENT NAME: SURNAME:

LOCAL ADDRESS:
VACATION ADDRESS:
MOBILE: EMAIL ADDRESS:
EMERGENCY CONTACT (1) NAME: MOBILE:
EMERGENCY CONTACT (2) NAME: MOBILE:

PLEASE TICK ALL CONDITIONS THAT APPLY NOW AND PUT AN A FOR PAST CONDITONS:
Heart, circulatory problems cancer/tumors Vision problems/contact lenses

High/low blood pressure Asthma or lung conditions Hearing problems

Varicose veins Hernias Fatigue
Blood clots Abdominal/digestive issues Depression
Phlebitis Arthritis Seizures/Stroke
Infectious disease Numbness/tingling Difficulty lying on your front/back
Rash, athletes foot Muscle/bone injuries Skin disorders
Allergies Muscle/joint pain Previous motor accident
Diabetes Chronic pain Other accident/trauma
Pregnancy Headaches/migraines Prosthesis or dentures

Other medical conditions or injuries not listed (past and present):

Current medications including aspirin, ibruprofen etc:

Recent surgery/surgeries:
Previous therapy/Fascia work:
Current recreational activities:

What increases the pain:

What decreases the pain:

ROM TESTING Findings:

MUSCLE TESTING Findings:

 POSTURE ASSESSMENT Findings:

CRITICAL PATH EXERCISES:

FASCIA RELEASING TECHNIQUES:

Statement of Consent:

I have received a description of the health and fitness testing that will be conducted, have read this
informed consent and have been given the opportunity to ask questions. I have been fully advised
regarding the nature of the procedures and the possible risks, and I hereby give my consent to
participate.

Sign Date
 ANNEXURE A - MUSCLE IMBALANCE AND PAIN LOCATOR
MARKER

Kyphosis TrP Hypertonicity

Lordosis Spasm Swelling
Scoliosis Adh Elevation
Neutral Rotation Pain
MANUAL MUSCLE STRENGTH GRADING

5 Normal Complete ROM against gravity with full

resistance
4 Good Complete ROM against gravity with
some resistance
3 Fair Complete ROM against gravity with no
resistance
2 Poor Incomplete ROM against gravity
1 Trace Slight contractility with no joint motion
0 Zero No evidence of muscle contractility

NECK AND TRUNK

SCORE AND FINDINGS
1 Neck flexion
2 Neck extension
3 Trunk flexion
4 Trunk rotation
5 Trunk extension

LOWER LIMB
1 Hip flexion
2 Hip extension
3 Hip abduction
4 Hip adduction
5 Hip lateral rotation
6 Hip medial rotation
7 Knee flexion
8 Knee extension
9 Ankle plantar flexion
10 Foot dorsiflexion and inversion
11 Foot inversion
12 Foot eversion
MANUAL MUSCLE STRENGTH GRADING
5 Normal Complete ROM against gravity with full
resistance
4 Good Complete ROM against gravity with
some resistance
3 Fair Complete ROM against gravity with no
resistance
2 Poor Incomplete ROM against gravity
1 Trace Slight contractility with no joint motion
0 Zero No evidence of muscle contractility

UPPER LIMB
SCORE AND FINDINGS
1 Scap abd and upward rotation
2 Scapula elevation
3 Scapula adduction
4 Scapula depression and add
5 Shoulder flex to 90
6 Shoulder extension
7 Shoulder abd to 90
8 Shoulder lat rotation
9 Shoulder med rotation
10 Elbow flexion
11 Elbow extension
12 Forearm supination
13 Forearm pronation
14 Wrist flexion
15 Wrist extension
16 Finger abduction
17 Finger adduction
18 Thumb abduction
19 Thumb adduction