Lumbar Extension Rotation Test Assessment
Please complete this form to provide information for your lumbar spine assessment using the extension rotation test.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Referring Provider or Clinic (if applicable)
Reason for Assessment / Presenting Complaint
*
Do you have a history of lumbar spine or lower back problems?
*
Yes
No
Describe your current symptoms (e.g., pain, stiffness, numbness)
*
Pain Severity (at rest and during movement)
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
0 is No pain, 10 is Worst pain imaginable
Which side is being tested?
*
Left
Right
Both
Test Findings
*
Rows
Positive
Negative
Notes
Extension-Rotation Left
1
2
Extension-Rotation Right
3
4
What aggravates your symptoms? (Select all that apply)
Bending backward
Rotating trunk
Prolonged sitting
Lifting objects
Other
What relieves your symptoms? (Select all that apply)
Rest
Stretching
Medication
Physical therapy
Other
Additional Notes (Clinician Use)
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