Kinetic Chain Assessment Form
Please complete all sections to help us evaluate your movement patterns and identify areas for improvement.
Participant Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Contact Email Address
*
example@example.com
Age
*
Gender
*
Male
Female
Other
Reason for Assessment
*
Current Areas of Pain or Discomfort (select all that apply)
Neck
Shoulder
Back
Hip
Knee
Ankle/Foot
No Pain
Other
Postural Assessment – Rate the following areas for alignment (1 = Poor, 5 = Excellent)
*
Rows
Head/Neck Alignment
Shoulder Alignment
Hip Alignment
Knee Alignment
Ankle Alignment
1
1
2
3
4
5
2
6
7
8
9
10
3
11
12
13
14
15
4
16
17
18
19
20
5
21
22
23
24
25
Movement Assessment – Rate the following movements (1 = Significant Dysfunction, 5 = No Dysfunction)
*
Rows
Squat
Lunge
Overhead Reach
Single Leg Balance
Trunk Rotation
1
26
27
28
29
30
2
31
32
33
34
35
3
36
37
38
39
40
4
41
42
43
44
45
5
46
47
48
49
50
Please rate your current pain level during movement (0 = No pain, 10 = Worst possible pain)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Have you experienced any previous injuries related to the kinetic chain?
*
Yes
No
If yes, please provide details of previous injuries (location, year, treatment, etc.)
General Health Status (select all that apply)
Diabetes
Hypertension
Heart Condition
Asthma
None
Other
Submit Assessment
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