Client Name: Level of Manual Functional
Static Active Reactive Comments
Support Level
Ref#: Pelvic / thigh Arms and hands
in alr except Maintain vertical neutral position of head
strap used except
as indicated as indicated and trunk above manual support level
Tester Name:
Minimurm of
While tur ning Maintain/ quickly
5 seconds head with arms regain following
Date: ifted brisk nudge
Shoulder girdle Head control
testers hand Arms may be NOT tested for
position may vary Supported head control
from horizontal throughout
Axillae
Upper Thoracic
Control
Mid Thoracic
Inferior Scapula
Control
Lower Thoracic
Over lower ribs
Control
Upper Lumbar
Below ribs
Control
Lower Lumbar
Pelvis
Control
No support given Full Trunk
and pelvic/thigh Control
straps removed
Fixed spinal
deformity? Yes D No Comments:
Limitation of
cervical rotation Left D Right Comments: