Gender
Year of Birth
NON-WEIGHTBEARING EVALUATION
1. Rearfoot/ STN position
__________ varus
2. Rearfoot/Calcaneal eversion
__________ degrees
3. Rearfoot/ Calcaneal inversion
__________ degrees
4. Rearfoot/ Ankle dorsiflexion
__________ degrees
5. Rearfoot/ Talar shift
Hypo/ Norm/ mild/ mod/ max
6. Forefoot/STN position
________° varus / valgus
7. Forefoot/ STN position
Rigid ______
or Flexible to:_____________
8. Forefoot/FF Equinus
No / Yes: small / Yes: large
9. First / Fifth Ray: STN position & mobility
________° varus / valgus
10. Forefoot: STN position
Rigid or Flexible
11. Hallux Dorsiflexion
__________ degrees
12. Arch Height
low/ med/ high
13. Toe Positions/Deformities:
14. Calluses:
WEIGHTBEARING EVALUATION
15. General Limb Position
Large Toe-out/ Mod Toe-Out/ Mild Toe-out/ Neutral/ Toe-In
16. Tibial Int. Rotation
none/ mild/ mod/ large
17. Heel Position To Floor
18. Arch Height: As compared to NWB
low/ med /high
19. Navicular drop
none/ mild/ mod/ large
20. Toe Sign
through long axis
of each individual foot
+1/ +2 /+3/ +4 /+5
or Peek A Boo Toe
21. Postural Observations: Suspected True LLD?
No /Yes
LEFT Short by_______RIGHT Short by_______
22. Postural Observations:Knee
________ Recurvatum
________ Genu Varum/Valgum