Assistive Devices Used

None Cane Walker Wheelchair Elbow Crutch Axillary Crutch

Braces / Orthoses Used

Back Support Knee Support Ankle Support Wrist Support Elbow Support Cervical Collar Silicone Pad Flat Foot Insole Silicone Insole

Posture

Normal Forward Head Kyphosis Scoliosis Anterior Pelvic Tilt

Deformities

Genu Varum Genu Valgum Leg Length Discrepancy Flat Foot Hallux Valgus Trigger Finger

Gait Pattern

Normal Antalgic Ataxic Trendelenburg Shuffling Circumductive High Stepping Assisted (e.g. cane, walker)

Swelling / Edema

Severity

Mild Moderate Severe

Type

Pitting Non-pitting

Skin Condition

Intact Redness Bruising Scar Open Wound Dry Rash

Pressure Ulcer Stage

Select stage I II III IV

Tenderness

0 (No tenderness) 1 (Tender to deep pressure) 2 (Tender to light pressure) 3 (Tender to touch with facial reaction and withdrawal) 4 (Unable to tolerate palpation)