Medical Exercise Functional Assessments

Clients Only

Find your appropriate functional scale(s) from the list and click to fill out, thank you!

Ankle Assessment
Shoulder Strength Scale
Tinetti / Gait Balance
Cervical Oswestry Scale
Harris Hip Function Scale
Lysholm Knee Scale

Functional Ankle Assessment

Client Name

First Name

Last Name

By typing my name below, I hereby acknowledge that this electronic signature serves as my legal signature.

Subjective assessment of the injured ankle:

Can you walk normally?

YES (15)

NO (0)

Can you run normally?

YES (15)

NO (0)

Climbing downstairs:

Rising on heels with injured leg:

Rising on toes with injured leg:

Single-limbed stance with injured leg:

Laxity of ankle joint:

Dorsiflexion ROM of injured leg:

Functional Shoulder Scale

Client Name

First Name

Last Name

By typing my name below, I hereby acknowledge that this electronic signature serves as my legal signature.

Pain:

ADLs:

Positioning:

Range of Motion:

Internal Rotation:

External Rotation:

Tinetti Gait/Balance Scale

Client Name

First Name

Last Name

By typing my name below, I hereby acknowledge that this electronic signature serves as my legal signature.

Sitting Balance

Arises:

Attempts to Arise:

Immediate standing balance (first 5 seconds):

Standing Balance:

Nudged (subject at max position with feet as close as possible, examiner pushes three with palm on subjects sternum):

Eyes closed (same as above) :

Turning 360 Degrees:

Sitting Down:

Initiation of Gait (immediate initiation)

Step length and height - RIGHT FOOT

Step length and height - LEFT FOOT

Step Symmetry

Step Continuity

Path (estimate 12 inch floor tiles over 10 feet)

Trunk

Walking Time

Cervical Oswestry Scale

Client Name

First Name

Last Name

By typing my name below, I hereby acknowledge that this electronic signature serves as my legal signature.

Pain intensity:

Personal Care:

Lifting:

Reading:

Headaches:

Concentration:

Work:

Driving:

Sleeping:

Recreation:

Harris Hip Function Scale

Client Name

First Name

Last Name

By typing my name below, I hereby acknowledge that this electronic signature serves as my legal signature.

Pain:

Range of Motion:

Gait --> Limp:

Gait --> Support:

Gait --> Distance Walked:

Stairs:

Socks and Tie Shoes:

Sitting:

Enter Public Transport:

Absence of Deformity (must have all four):

Lysholm Knee Scale

Client Name

First Name

Last Name

By typing my name below, I hereby acknowledge that this electronic signature serves as my legal signature.

Limp:

Support:

Stair Climbing:

Squatting:

Instability:

Swelling:

Pain:

Atrophy of Thigh:

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Medical Exercise Functional Assessments

Clients Only

Find your appropriate functional scale(s) from the list and click to fill out, thank you!

Functional Ankle Assessment

Functional Shoulder Scale

Tinetti Gait/Balance Scale

Cervical Oswestry Scale

Harris Hip Function Scale

Lysholm Knee Scale

Need Help Getting Started?

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