Lower Quarter Screening in Pediatrics

Childs Name: ________________________________

AGE _______
Teachers name_______________________________
Room number______________

1.

WALKING
Velocity

Normal

_________________________________________________

Cadence

Normal

_________________________________________________

Stride length

Normal

_________________________________________________

Stance phase problem _____________________________________________________________

Swing phase problem _____________________________________________________________
2.

SKIPPING

___________________________________________________________________

3.

JUMPING/HOPPING

4.

HEEL WALK

__ normal ___________________________________________________

5.

TOE WALK

__ normal ___________________________________________________

6.

POSTURE (POST) _____________________________________________________________

_________________________________________________________

___________________________________________________________________
7.

POSTURE (ANT)

_____________________________________________________________

___________________________________________________________________
8.

POSTURE (LAT)

_____________________________________________________________

___________________________________________________________________
9.

SCOLIOSIS

__ normal ___________________________________________________

Curve description_______________________________________________________________
10.

SIT TO STAND

11.

EXAMINATION IN SUPINE
Observation ___________________________________________________________________
Palpation

12.

__ normal ___________________________________________________

___________________________________________________________________

EXAMINATION IN SUPINE
Straight Leg Raise
Hip internal rotation
Hip external rotation
Hip flexion
Hip extension (flex contracture)
Hip adduction
Hip abduction

Right
_______
_______
_______
_______
_______
_______
_______

left
________
________
________
________
________
________
________

Comments
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________

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Lower Quarter Screening in Pediatrics

Childs Name: ________________________________
AGE _______
Teachers name_______________________________
Room number______________

Knee ext. to flexion

13.

14.

_______

________

_________________________

EXAMINATION IN SUPINE
MMT
Right
___________________
______

left
______

Comments
_____________________________

___________________

______

______

_____________________________

___________________

______

______

_____________________________

___________________

______

______

_____________________________

___________________

______

______

_____________________________

EXAMINATION IN PRONE
Observation

_________________________________________________________________

Palpation

_________________________________________________________________

15.

EXAMINATION IN PRONE
Hip internal rotation
Hip external rotation
Tibial Torsion
Ankle dorsiflexion
Ankle plantar flexion
Subtalar INV
Subtalar EVER
Midtarsal motion (TNJ)
Midtarsal motion (CCJ)
Metatarsus varus

16.

EXAMINATION IN PRONE
MMT
Right
___________________
______

left
______

Comments
_____________________________

___________________

______

______

_____________________________

___________________

______

______

_____________________________

___________________

______

______

_____________________________

___________________

______

______

_____________________________

17.

Joint laxity testing

Right
_______
_______
_______
_______
_______
_______
_______
_______
_______
_______

left
________
________
________
________
________
________
________
________
________
________

Comments
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________

_ normal ____________________________________________________

Cardiac Blood Pressure Testing

Heart Rate: Normal: ______ Abnormal: _______Rhythm _________ Rate: ____________
Blood Pressure: Sitting: UE ______________ (L) UE _____________________

Revised 032111
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Lower Quarter Screening in Pediatrics

Childs Name: ________________________________
AGE _______
Teachers name_______________________________
Room number______________

NOTES: ___________________________________________________________________________

Revised 032111
3