Date of Test:

-- mm/dd/yy

          Applicant Information:

First Name
Last Name
Date of Birth	(mm/dd/yyyy)
Sex	Male Female
Height (inches)
Weight (lbs)
SS Number

          Company Name and Position:

Company Name	ShortStop
Position	Laborer
Rig Number

          PDC Level:

Sedentary Light Medium Heavy Very Heavy

Hand Dominance:

          Right Left

Cardiovascular Status:

Resting Heart Rate
15-sec Pulse after Step Test
Cardiovascular Status
Blood Pressure
Release Required?	Yes No

          Cervical Lordosis:

Normal Increased Decreased

Thoracic Kyphosis:

Normal Increased Decreased Dowager's Hump

Thoracic Scoliosis:

Normal Left C-Curve Right C-Curve S-Curve

Lumbar Lordosis:

Normal Increased Decreased

PSIS Levels:

Level Right Elevated Left Elevated

Grip Test Average - Right

Grip Test Average - Left

Crepitus Evaluation

Joint Crepitus - Upper Extremities

WNL Abnormalties Found

          Joint Crepitus - Lower Extremities

          WNL Abnormalties Found

Description of Joint Crepitus Abnormalities

Laxity Evaluation

Joint Laxity - Upper Extremities

WNL Abnormalties Found

          Joint Laxity - Lower Extremities

          WNL Abnormalties Found

          Description of Joint Laxity Abnormalities

         

Range of Motion

Cervical Flexion

Cervical Extension

Cervical SB - Right

Cervical SB - Left

Cervical Rotation - Right

Cervical Rotation - Left

Lumbar Flexion

Lumbar Extension

Lumbar SB - Right

Lumbar SB - Left

Extremities' ROM

WNL Limitations Found

Describe any extremity ROM limits

Strength Testing

Shoulder Shrugs - Right

5 4 3 2 1

Shoulder Shrugs - Left

5 4 3 2 1

Shoulder Abduction - Right

5 4 3 2 1

Shoulder Abduction - Left

5 4 3 2 1

Wrist Extension - Right

5 4 3 2 1

Wrist Extension - Left

5 4 3 2 1

Elbow Extension - Right

5 4 3 2 1

Elbow Extension - Left

          5 4 3 2 1

Thumb Extension - Right

5 4 3 2 1

Thumb Extension - Left

5 4 3 2 1

5th Finger Adduction - Right

5 4 3 2 1

5th Finger Adduction - Left

5 4 3 2 1

Hip Flexion - Right

5 4 3 2 1

Hip Flexion - Left

5 4 3 2 1

Knee Extension - Right

5 4 3 2 1

Knee Extension - Left

5 4 3 2 1

Ankle DF/Inv - Right

5 4 3 2 1

Ankle DF/Inv - Left

5 4 3 2 1

1st Toe Extension - Right

5 4 3 2 1

1st Toe Extension - Left

5 4 3 2 1

Knee Flexion - Right

5 4 3 2 1

Knee Flexion - Left

5 4 3 2 1

Hip Extension - Right

5 4 3 2 1

Hip Extension - Left

5 4 3 2 1

LMN Reflexes

Biceps

0 1+ 2+ 3+

Brachioradialis

0 1+ 2+ 3+

Triceps

0 1+ 2+ 3+

Patellar

0 1+ 2+ 3+

Achilles

0 1+ 2+ 3+

Comments on LMN Reflexes

UMN Reflexes

Scapulohumeral

Positive_Right Positive_Left Negative

Babinski's

Positive_Right Positive_Left Negative

Special Testing

Supine SLR Degrees - Right

Supine SLR Degrees - Left

Alignment of Spinous Processes

WNL Abnormalities

Abnormalities Found

Standing Kemp Test

Positive_Right Positive_Left Negative

Spurling Test

Positive_Right Positive_Left Negative

Dynamic Lifting Tests

Floor to Knuckle Lift

Reason F-K Stopped

Maximum Safe Effort Unsafe Body Mechanics Applicant Request Weight Limit Achieved

12" to Knuckle Lift

Reason 12"-Kn Stopped

Maximum Safe Effort Unsafe Body Mechanics Applicant Request Weight Limit Achieved

Knuckle to Shoulder Lift

Reason Kn-Sh Stopped

Maximum Safe Effort Unsafe Body Mechanics Applicant Request Weight Limit Achieved

Shoulder to Overhead Lift

Reason Sh-OH Stopped

Maximum Safe Effort Unsafe Body Mechanics Applicant Request Weight Limit Achieved

Body Mechanics

Good Fair Poor Unacceptable

Education given regarding body mechanics?

Yes No

Functional Job Activity #1 Description

Subject will lift a standard NIOSH box with 50 lbs from floor to chest x 5 reps, and from floor to overhead with 25 lbs x 5 reps.

Body Mechanics

Good Fair Poor Unacceptable

Post-Activity Heart Rate

FJA #1 Results

Capable Not Capable

Functional Job Activity #2 Description

Subject will perform a two-hand carry with 25 lbs x 50 feet.

Body Mechanics

Good Fair Poor Unacceptable

Post Activity Heart Rate

FJA #2 Results

Capable Not Capable

Functional Job Activity #3 Description

Subject will perform a one-hand carry with 15 lbs up and down stairs or ladder and even sufaces for 1 rep or 50 feet. One rep each side.

Body Mechanics

Good Fair Poor Unacceptable

Post Activity Heart Rate

FJA #3 Results

Capable Not Capable

Functional Job Activity #4 Description

Subject will perform repetitive crouching and repetitive forward bending at the waist x 1 minute each.

Body Mechanics

Good Fair Poor Unacceptable

Post Activity Heart Rate

FJA #4 Results

Capable Not Capable

Functional Job Activity #5 Description

Patient will perform static kneeling x 1 minute.

Body Mechanics

Good Fair Poor Unacceptable

Post Activity Heart Rate

FJA #5 Results

Capable Not Capable

Applicant's Conduct

Cooperative      Uncooperative              

Overall Test Results

Pass Fail - Medical Risk Fail - Essential Functions Fail - Falsified Information Hold - Risk Factors Identified

Comments On Job Specific Testing

Clinician Name