THE MCKENZIE INSTITUTE
LOWER EXTREMITIES ASSESSMENT
DateNameGender

Address
Telephone
Date of BirthAge

Referral: GP / Orth / Self / OtherWork demands

Leisure activities

Functional limitation for present episode __________________________________________________________________________________
Outcome / Screening score
NPRS (0-10)
Present symptoms
Present since

improving / unchanging / worsening

Commenced as a result ofno apparent reason

Symptoms at onset

Paraesthesia: yes / noSpinal history

Cough / Sneeze +ve / -ve

Constant symptoms:

WorseIntermittent symptoms:

bending

sitting / rising / first few steps

am / as the day progresses / pm

standing

walkingstairswhen still / on the movesquatting / kneeling

Sleeping: prone / sup / side R / L

Other
Betterbending

sitting

standing

am / as the day progresses / pm

walkingstairswhen still / on the movesquatting / kneeling

Sleeping: prone / sup / side R / L

otherContinued use makes the pain:
Pain at rest

betterworse

no effect

yes / noOther Questions:

Disturbed sleep

Site:swelling

yes / noback / hip / knee / ankle / footcatching / clicking / locking

giving way / falling

Previous history
Previous treatments
Medications ______________________________________________________________________________________________
General health / Comorbidities: __________________________________________________________________________________________________________________________ Recent / relevant surgery: yes / no
History of cancer: yes / no____________________________

Unexplained weight loss: yes / no

History of trauma: yes / no __________________________________

Imaging: yes / no___________________________

Patient goals / expectations:©McKenzie Institute International 2020

EXAMINATIONPOSTURAL OBSERVATION
Sitting:
lordotic / neutral / kyphotic
Other observations:
NEUROLOGICAL:

Change of posture:better / worse / no effectStanding:

lordotic / neutral / kyphotic

NA / motor / sensory / reflexes / neurodynamic

BASELINES: Pain and functional activity
EXTREMITIES

hip / knee / ankle / foot

MOVEMENT LOSS

Maj

ModMinNil

Symptoms

Maj

ModMinNil

Symptoms

Adduction /Inversion
Abduction /Eversion

FlexionExtension
Dorsi Flexion
Plantar Flexion
Other:

Internal Rotation
External Rotation
Other:

PDM

Passive Movement: note symptoms, range and +/- over pressure:

ERP

Resisted test pain response
Other tests / static positioningSPINE
Movement Loss
Effect of repeated movements
Effect of static positioning
Spine testing

not relevant / relevant / secondary problem

Baseline Symptoms
Repeated Tests
Active / Passive movement,
resisted test, functional test

PROVISIONAL CLASSIFICATION

Symptomatic Response
DuringProduce, Abolish,
Increase, Decrease, NE

Mechanical Response

After
Better, Worse, NB, NW,
NE

Extremities

Effect or ROM, strengthor key functional test

NoEffect

Spine

Derangement ___________________________________ Directional Preference _______________________________________
Dysfunction: Articular / Contractile ____________________ Postural
POTENTIAL DRIVERS OF PAIN AND / OR DISABILITY

Comorbidities

OTHER subgroup: __________________________
Cognitive - Emotional

Contextual

Descriptions:____________________________________________________________________________________________
PRINCIPLES OF MANAGEMENT
Education
Exercise type ___________________________________ Frequency ___________________________________________________
Other exercises / interventions _____________________________________________________________________________
Management goals_________________________________________________Signature _____________________________________________©McKenzie Institute International 2020