Primary injury/complaint:
- Lower back pain, onset 2 weeks ago following a heavy lifting incident.
ROM & Posture (VALD DynaMo):
Cervical:
- Within normal limits.
Thoracic:
- Mild kyphosis noted.
Lumbar:
- Reduced flexion, pain on extension.
Other:
- Nil.
Posture:
- Forward head posture, rounded shoulders, slight pelvic tilt.
Gait:
- Antalgic gait, favouring the right side.
VALD Functional tests (Force Decks) (to be used as a guide only, upload results to file):
Stand to Sit to Stand:
- Reduced power output, difficulty with the eccentric phase.
Squat:
- Limited depth, pain reported.
Lunge:
- Asymmetry noted, right side more restricted.
Standing Balance:
- Reduced balance on the right leg.
Calf Raise:
- Bilateral weakness.
Single Leg Squat:
- Unable to perform due to pain.
Single Leg Hop:
- Unable to perform due to pain.
Countermovement jump:
- Reduced jump height.
Push Up (wall, knees, toes):
- Unable to perform due to pain.
Other VALD measurements:
- Nil.
Other functional tests:
Straight Leg Raise:
- Positive on the right, limited to 60 degrees.
Bent Knee Fall Out:
- Pain on the right side.
Pelvic Tilts:
- Anterior pelvic tilt noted.
Bridge:
- Weakness noted.
Supine Roll-Up:
- Pain reported.
Goal Post:
- Nil.
Four Point Kneel/Bird dog:
- Difficulty maintaining neutral spine.
Other Tests Specific to Injury:
- Thomas test positive for right hip flexor tightness.
RTUS (Consent gained Yes/No):
- Yes
Position of Ax:
- Supine, prone, standing.
Pelvic Floor:
- Nil.
Transverse Abdominis:
- Weakness noted.
Breathing:
- Shallow breathing pattern.
PF cued through TrA: Yes/No
- No
Asymmetries/accessory movements:
- Right side rotation restriction.
Womens health check:
- Nil.
Primary injury/complaint:
- [describe primary injury or complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
ROM & Posture (VALD DynaMo):
Cervical:
- [describe cervical ROM and posture findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Thoracic:
- [describe thoracic ROM and posture findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Lumbar:
- [describe lumbar ROM and posture findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other:
- [describe other ROM and posture findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Posture:
- [describe posture findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Gait:
- [describe gait findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
VALD Functional tests (Force Decks) (to be used as a guide only, upload results to file):
Stand to Sit to Stand:
- [describe findings from Stand to Sit to Stand test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Squat:
- [describe findings from Squat test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Lunge:
- [describe findings from Lunge test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Standing Balance:
- [describe findings from Standing Balance test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Calf Raise:
- [describe findings from Calf Raise test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Single Leg Squat:
- [describe findings from Single Leg Squat test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Single Leg Hop:
- [describe findings from Single Leg Hop test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Countermovement jump:
- [describe findings from Countermovement jump test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Push Up (wall, knees, toes):
- [describe findings from Push Up test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other VALD measurements:
- [describe other VALD measurements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other functional tests:
Straight Leg Raise:
- [describe findings from Straight Leg Raise test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Bent Knee Fall Out:
- [describe findings from Bent Knee Fall Out test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Pelvic Tilts:
- [describe findings from Pelvic Tilts test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Bridge:
- [describe findings from Bridge test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Supine Roll-Up:
- [describe findings from Supine Roll-Up test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Goal Post:
- [describe findings from Goal Post test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Four Point Kneel/Bird dog:
- [describe findings from Four Point Kneel/Bird dog test] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Other Tests Specific to Injury:
- [describe other tests specific to injury] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
RTUS (Consent gained Yes/No):
- [state if consent was gained for RTUS] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Position of Ax:
- [describe position of assessment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Pelvic Floor:
- [describe pelvic floor findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Transverse Abdominis:
- [describe transverse abdominis findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Breathing:
- [describe breathing findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
PF cued through TrA: Yes/No
- [state if pelvic floor was cued through transverse abdominis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Asymmetries/accessory movements:
- [describe asymmetries or accessory movements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Womens health check:
- [describe findings from women's health check] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
