MCKENZIE INSTITUTE ASSESSMENT FORMS
Guidelines for the Completion of the Assessment Forms
History: Page One
Patient responses are recorded but supplemented by the clinician as appropriate

Referral:Circle the appropriate, may record date of follow-up
appointment.

Postures / Stresses:

Work: Mechanical stresses:
Record work activities and indicate frequency of activity
e.g. 50% sitting, 50% standing.
Leisure: Mechanical stresses:
Record leisure or hobby activities and indicate
frequency of activity e.g.; 75% sitting, 25% bending orcould say walking 3x week 40 mins, gardening3hours/week for example.

Functional Disability fromPresent Episode:Ask patient specific activities that they are unable toperform or have difficulty performing because of current
symptoms.

Functional Disability Score:

Note the test being used, and the score.

VAS Score:

Tend to scale the intensity of the pain, must include
most distal pain. Can use to define pain range, not justits upper limit.

Body Chart:

Used to record “all symptoms this episode” i.e. all thesymptoms the patient is complaining of, not signs. All
symptoms may not still be present.

Present Symptoms:

Record here the location/type of symptoms that are stillconcerning the patient. May differ from the body chart
as not all may still be present.

Present Since:

Usually given in weeks or days. Can write a specificdate if known or if needed for legal reasons.

Improving / Unchanging /Worsening:

Circle as appropriate, and ask patient how, or in whatway, if they say they are improving or worsening.

Commenced as a Result of:If appropriate describe mechanism of injury e.g. lifting
and twisting Or circle no apparent reason.

Symptoms at Onset:

Circle give time frame of onset of distal pain e.g. circle
back then comment 2 days later in the leg.

Constant / Intermittent:

Circle as appropriate. Back = to gluteal fold, Thigh =above knee, Leg = below knee.

Better / Worse Section:

Recording
Circle for always – if not clarified this means immediatepain response. If relates to time need to clarify outside
the circle with e.g. 10minutes, prolonged. Line under –sometimes. Oblique line through – no effect.
Put a ? above activity if patient still unsure even after
further questions, rather than leave blank.
If two unrelated areas of pain may need to indicate if
dealing with back or leg pain for each activity.

History: Page One
Patient responses are recorded but supplemented by the clinician as appropriate

Disturbed Sleep:

If always circle Yes, sometimes underline Yes. Not
affected circle No. If was previously circle Yes but write“previously”.

Sleeping Postures:

Circle usual, indicate if unable to use this because ofcurrent pain and indicate present position – best andworse.

Sleeping Surface:

Circle as appropriate.

Previous Episodes:

Circle 0, between 1-5 episodes, 6-10 episodes or 11+,indicate year of first episodePrevious History:

Write if episodic, which areas affected before and what
was it like between episodes, e.g. 100% between
episodesPrevious Treatment:

Write what treatments they have had for this episodeand, if appropriate what treatments/interventions they
have had for previous episodes. May indicate what hashelped if appropriate.

Specific Questions:Circle appropriate answers and write any clarifications
on the lines provided.

Physical Examination: Page Two

It is not essential to perform all components of the Physical examination with every patient.
If any section is not performed an oblique line is drawn through it.
Posture:Circle appropriate response.

Correction of Posture:

Circle response and indicate which pain changes if
appropriate.

Other Observations:

Record any significant musculo-skeletal differences,e.g. wasting, swelling redness etc.

Neurological Examination:

Qualify which deficit in each section, recorded if
abnormal, e.g. decreased S1 reflex. Can add Babinski /Clonus to reflexes if required.
Record as NAD if testing was normal. Oblique line
through if not applicable

Movement Loss:

The boxes Maj/Mod/Min/Nil can be used as a line i.e.
more as a continuum. Can also record as a tick in the“pain” box, if patient is reporting pain, indicate locationof the pain.

Test Movements:

Indicate the order performed by numbering if order isdifferent to standard. Useful also to record the numberof repetitions performed to gain the response.
Symptomatic response - Use standard terms only.
Monitor and describe effect on most distal symptoms
predominantly.
Mechanical response – Tick appropriate box. Can
indicate which movement has been effected by thechange if it is different to the one being tested.

Static Tests:

Record with standard “After” words.

Physical Examination: Page Two

Other Tests:

State which and the response achieved.

Provisional Classification:

Circle the classification, record the pain location forDerangement, indicate the direction of Dysfunction, orclarify the type of Other.

Principle of Management:

Education Circle - Record specifics, e.g. posturecorrection, avoidance of flexion. Mechanical Therapy- Circle Yes or No and write the specific exercises on
the line for Extension Principle, Flexion Principle or
Lateral Principle.
Treatment Goals – Indicate what you expect to changeby next visit and things you wish to reassess on Day 2.
Short and Long term goals can be recorded also.